SHERIFFS SIGNATURE_REDEACTED.PDF

MARICOPA COUNTY BOARD OF SUPERVISORS
301 West Jefferson Street, 10th Floor, Phoenix, Arizona 85003
APPLICATION FOR FIREWORKS DISPLAY
Arizona Revised Statutes § 36-1603 requires every display shall be handled by a competent operator, and shall
be of a character and located, discharged and fired so that it will not be hazardous to property or endanger any
person. Before a permit is granted, the operator, location and handling of the display shall be approved by the
sheriff of the county. After a permit is granted, the sale, possession, use and distribution of fireworks for the
display shall be lawful for that purpose only. Permits are not transferable or assignable.
Further, A.R.S. § 36-1604 requires that the governing body shall require each applicant to provide a satisfactory
bond of not less than $500, or a copy of the certificate of liability insurance in a principal amount usually not less
than $1 million, conditioned upon payment of all damages which may be caused to persons or property by
reason of the display.
Complete the following application and submit to the Clerk of the Board of Supervisors, 301 W. Jefferson Street,
10th Floor, Phoenix, 85003 (602-506-3766) at least 30 days prior to the event date.
All applications must have the following documentation attached:
1. Proof of appropriate bond or insurance payable to Maricopa County.
2. Map of display area.
3. List of fireworks to be discharged. The Director of Display for the fireworks company is expected to be
licensed and/or trained by the City of Phoenix or have other verification of expertise.
4. Verification from local fire department that they were notified of event, date, location and time.
EVENT INFORMATION
Name/Organization: Leisure World Community
Name of Event: New Year's Eve Fireworks
Event Address: 908 S. Power Road, Mesa AZ 85206
Date and Time of Event: December 31, 2019 @ 10:00pm
DISPLAY DIRECTOR (permit will be issued to the following)
Name: Sarah Harris Phone: 480-948 -0090
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address: Email:
SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO:
Maricopa County Clerk of the Board of Supervisors Email: ClerkBoard@mail.maricopa.gov
301 W. Jefferson Street, 10 th Floor Fax: 602-506-6402
Phoenix, Arizona 85003
For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766.

FIREWORKS DISPLAY SITE MAP
Indicate the following:
1. North direction 5. Fire department access
2. Distance from firing area to impact/fallout area 6. Hydrants
3. Spectator location 7. Distance to structures
4. Storage area 8. Overhead lines
(North)
See Attached
email to Clerk of the Board

FOR DEPARMENT USE ONLY:
SHERIFF'S OFFICE RECOMMENDATION
The State Fire Marshal or local fire chief has reviewed the site and fireworks described by the applicant and
found them to be satisfactory.
c;,ot_ ,/_ au #945 12/06/19
Date
PERMIT FOR FIREWORKS DISPLAY
The above application having been filed pursuant to A.R.S. § 36-1603, together with other proper
documentation; permission is granted to the above-named applicant to conduct a fireworks display on the dates
set forth in the application. IN THE EVENT OF POSTPONEMENT OF SAID SHOW, the display will be given
not later than one (1) week from the date specified above.
Approved by the Maricopa County Board of Supervisors:
DATED this day of 20
Clerk of the Board, authorized signature

EXHIBIT A
LEISURE WORLD COMMUNITY
Mesa
New Year's Eve
10:00 pm
Tuesday, December 31, 2019
6 - 8 minute display
Total Aerial Effects 419
Total Shells 219 Total Effects in Basins 200
Opening:
Leisure World's fantastic celebration of the New Year begins with an impressive
series of powerful booms and fiery, gorgeous color to excite and thrill your guests.
7 - 3" Color Shells
Aerial Display:
A large assortment of brilliantly-colored shells, including Chrysanthemums, Waves,
Crowns, Peonies, Brocade Crowns, Diadems, and Crossettes in gorgeous Reds,
Yellows, Blues, Greens, Silvers, and Golds.
Your Aerial Display will contain a total of 163 aerial shells and 200 basin effects.
1 1/2" - 2 EPA Premier Specialty Basins
3" - 163 Chinese Fancy's & Specials
Grande Finale:
Your celebration will close in spectacular excitement as multiple styles of brilliantly-
colored shells, rocket skyward growing and glowing in breath-taking Blues, Golds,
Greens, Silvers, Yellows, Purples and Red.
Your Grande Finale consists of 49 — 3" aerial shells.
Desisned for the Leisure World Community by: 5-rework5 Productions olArizona

----- 'I ® DATE (MM/DDNYYY)
ActoRE, CERTIFICATE OF LIABILITY INSURANCE 11/18/2019
THIS kas...---"--- CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT NAME: Janet Nau
The Partners Group Ltd ANC, PHONE No E - I I FAX (A/C, go): 425-455-6727
11225 SE 6th St., Suite 110 E-MAIL
Bellevue WA 98004 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: THE. Insurance Company 12866
INSURED 16021 INSURER B: Travelers Property Casualty Co of America 25674
FPA, LTD INSURER C :
Fireworks Productions of Arizona
17034 S. 54th Street INSURER D :
Chandler AZ 86226 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 466963777 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VVHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER (MM/DDIYYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS
LTR INSR WVD
A GENERAL LIABILITY Y CPP010586203 10/9/2019 10/912020 EACH OCCURRENCE $ 1,000,000
PREMISES DAMAGE TO (Ea RENTED occurrence) $ 600,000
X COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE I X .I OCCUR MED EXP (Any one person) $ N/A
PERSONAL & ADV INJURY $ 1,000,000
X $2000 Deductible
GENERAL AGGREGATE $ 10,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
$
---1 POLICY x T8-f LOC COMBINED SINGLE LIMIT
A AUTOMOBILE LIABILITY CPP010586203 10/9/2019 10/9/2020 (Ea accident) $ 1 000 000
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED x SCHEDULED BODILY INJURY (Per accident) $
AUTOS x 1A4R6-Cst AUTOS V VNED (Per PROPERTY accident) DAMAGE $
X HIRED AUTOS
$
UMBRELLA LIAR X OCCUR ELP001232903 10/912019 10/9/2020 EACH OCCURRENCE $ 9,000,000 GL On!
X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 9,000,000 GL on!
$
DED I RETENT ON $ 10/9/2019 10/9/2020 X WC STATU- OTH
B WORKERS COMPENSATION 1K643590 — Arizona TORY LIMITS ER
AND EMPLOYERS' LIABILITY Y / N EL EACH ACCIDENT $ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE 1 1 N/A
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000
(Mandatory in NH)
lives, describe under E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS below 10/9/2019 10/9/2020 Each Occ../Agg. $4,000,000
A Auto Excess Liability -Occurrenc ELP001291101 ELP001291201 10/912019 10/9/2020 Each Occ/Agg. $5,000,000
A Auto Excess Liability - Occurrenc
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more appear space as Is respects required) operations performed by or on behalf of the
The following are included as Additional Insured on General Liability as their interest may
Named Insured, as required by written contract.
Date of Display: December 31, 2019
Location of Display: Coyote Run Golf Course at Leisure World Community, Department; Mesa Leisure World Community Association; Coyote Run Golf Course,
Additional Insured(s): State of Arizona; Maricopa County; Rural Metro Fire
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Leisure World Community Association
908 S. Power Road AUTHORIZED REPRESENTATIVE
Mesa AZ 85206 ..„-,....__
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1
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD

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Site
Fireworks Map
Water 2 Class
Productions Fire 2-A
say Extingui Pres
of
Site
Arizona
Maximum
Shell e
480-948-0090 Size: .1Dati-043713-/2-013,
3"
Shells
info@fireworksaz.com
Mesa, Leisure
AZ WorIci

Mia Vargas (COB)
From: Sarah Harris <sarah@fireworksaz.com >
Sent: Tuesday, December 3, 2019 8:59 AM
To: Mia Vargas (COB)
Subject: FW: EXT: Permit Request
Please see below the email from the responding fire department.
Pyro Office Manager
Pyrotechnician
Fireworks
Production
Arizona
480-948-0090 (office)
480423-5430 (fax)
1-877-948-0090 (toll-free
17034 S. 54th Street, Chandler, AZ 85226
From: Diamond, Kenneth [mailto:Kenneth.Diamond@ruralmetrofire.com]
Sent: Monday, December 02, 2019 4:38 PM
To: Sarah Harris
Subject: RE: EXT: Permit Request
Hello
We are aware of the fireworks display on New Years Eve at 908 S. Power rd Mesa, AZ
We are the AHJ and responding fire department of the area.
Kenneth Diamond
Fire Captain
Deputy Fire Marshal
Rural/Metro Fire Central Arizona
7631 E. Main St Mesa, AZ 85207
C: 480.869.2340

0: 480.380.3700 x Option 4
From: Sarah Harris <sarah@fireworksaz.com >
Sent: Friday, November 22, 2019 2:12 PM
To: Diamond, Kenneth <Kenneth.Diamond@ruralmetrofire.com >
Subject: EXT: Permit Request
Hello Sir,
Attached is the permit request for the Leisure World Community New Year's Eve fireworks display. If you have any
questions please do not hesitate to contact our office. Thank you
Sarah
Pyro Office Manag
Pyrotechnician
480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)
17034 S. 64th Street, Chandler, AZ 86226
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