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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:Anthem Name of Event: July 3rd, 2019 Fireworks Display Event Address:41703 N. Gavilan Peak Parkway, Anthem AZ. 85086 Date and Time of Event: July 3rd, 2019 @ 9:00 PM DISPLAY DIRECTOR (permit will be issued to the following) Name: Randy Reyman Phone: 602-448-1033 Business: Reyman Pyrotechniques/Any Pyro Fax: 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) 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. Sheriff's Office Signature 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 Certificate of Insurance 19943 Issue Date: 4/5/2019 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF Professional Program Insurance Brokerage INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE 371 Bel Mann Keys Blvd ., Suite #220 CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY Novato, California 94949 THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED INSURER A: Underwriter's at Lloyd's, London Randy Reyman INSURER B: DBA: Any Pyro DBA: Re man P rotechniques INSURER C: INSURER D: COVERAGES: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE (DD/MM/YY) DATE (DD/MM/YY) A GENERAL LIABILITY PY/18-0208 11/22/2018 11/22/2019 EACH ACCIDENT $1,000,000 t'N CLAIMS MADE MEDICAL EXP (any one person) FIRE LEGAL LIABILITY $50,000 GENERAL AGGREGATE $2,000,000 PRODUCTS-COMP/ OPS AGG DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is additional insured as respects the following: Date(s) of Display: 7/3/2019 Location: Anthem Community Park Additional Insured: Anthem Community Council, Inc.; Anthem Parkside Community Association, Inc.; Anthem Country Club Community Association, Inc.; Daisy Mountain Fire District, State of Arizona, Maricopa County. Ptirsiiertt taArizena Revised Stetutes section 20-4111,01, Rain Date(s): 7/3/2019 subsection B, paragraph 1; this policy is issued by an insurer that does not possess a certificate of authority from the director of the Arizona Department of Insurance. If the insurer that issued this policy becomes insolvent, insureds or claimants will not be eligible for Type of Display: Aerial Fireworks Display insurance guaranty fund protection pursuant to Ari7nna Revised Statues title 20. CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXIPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS Anthem Community Council, Inc. WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS 3701 W. Anthem Way, Ste. 102 AGENTS OR REPRESENTATIVES. Anthem, AZ. 85086 a .of AUTHORIZED REPRESENTATIVE (.1 HEM COMMUN 7 PARK 04'• 4 41703 N. Gavillan Peak PkWyQ ntiireflat, - ntftstui Plroworks fall out gone: Cars/people are prohibited In this area unless they have prior approval and are IEEE part of the event operations. ompstiosolonoomioilijowitoutrotomplooto lif Launch site: This Is where the fireworks are set up 14Iiitt; and launched from, Only pyrotechnics and DMFD are Oatit 1 allowed in this area. 11 IN 14 111 NI 01 WM 4( 14 IN s MillIN MI 10 I igIiiwri 2414.6tha fietiVitAr ' MEI= Nottilite Hell ell i E---,---1 I S o c E/ I Miatatuie Fialitt3; r 1 I kcijuitLQuptaggeas, Preen Security will have one person posted in 110.10.oloIgnivAleiltenti these locations during event hours, Parking lot en- Iftosttl4aitilko!* trance starting at 4pm, All others members of the team will roam the park IfIffironan DSAK Security will always have one person at these areas during event hours. DBAK point of con. madas tact will be first call made via radios and will dis- iiu 6 Satilboa Playgrromid patch from there to Posse and Deputies, All other ik 7 Baseball! (0) tIo5tvocpun Deputies will roam and shift to where needed, r)elt CoMailieliAleatvocia ride 9 ChM' Anthem Vootiwos MentowhIll Posse will cover these areas , shifting to roadwa) vle 10 Main Pavnionti nahy Ilitmorntr i lroad iyaq duties when needed. t 009 sAtri.-Yek anthem shells Reyman Pyrotechniques/Any Pyro Anthem Display, 7/3/19 Content of display Following is the shell content of the display: 2 1/2 inch shells-62 3 inch shells-239 4 inch shells-180 5 inch shells-142 6 inch shells-12 1-120 shot Brocade Crown Scattering barrage box 1-50 shot Hail to the Homeland barrage box Page 1 4 v, jp:WkAladt)iiid ttatsEu , • • nt . 111014J1 Tooriyiubly; btItttilAWAtOri MEMBER ID: ;RIAV11:1-3V kEVIN/AN REYMAN PYROTECHNICQUES 11111 111111111111 11 IMPIMS1111=11110 _. ViCitilit'l* ..- . a - ' City of Flagstaff Fire Department 211 W. Aspen Avenue Flagstaff, AZ, 86001 Pyrotechnics Permit App an Permit DL# DOE SSW Issued By: Firo Inspector Date Issued: IDENTIFICATION NAME —1 L Re ADDRESS DRIVER'S uC.ri THIS CERTIFICATE IS NOT TRANSFERABLE AND MAY BE REVOKED FOR-CAUSE NOT TO BE USED OUTSIDE CITY OF PHOENIX 95.100D New 5/07 DAISYMOUNTAIN 41018 N DAISY MOUNTAIN DR ANTHEM, AZ 85086 Permit Certificate DMFD Date: 05/07/2019 Business Name: ANY PYRO Address: Phone: The following permit has been issued: Permit No. 1819-226 Type: FIREWRKS FIREWORKS SALES/DISPLAY Issued Date: 05/07/2019 OCCUPANT LOAD: 0 Effective Date: 07/03/2019 Expiration Date: 07/03/2019 Notes: ANY RYRO e re ve,, 0 Daisy Mountain Penn it # I gicl -aa(r) It is the business's responsibility to ensure that conditions are in accordance with applicable State and Local fire regulations. Obtain any permits that are required by the State of Arizona and the County having jurisdiction. Inspector:DMFD FIRE PREVENTION Date 05/07/2019 05/07/2019 15:06 Page 1