ST. ROSE PHILIPPINE DUCHESNE CATHOLIC PARISH REDACTED.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,
101h 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: St. Rose Philippine Duchesna Catholic Parish
Name of Event: Fall Festival Fireworks
Event Address: 2825 W Rose Canyon Circle, Anthem AZ 85086
Date and Time of Event: October 13, 2018 @ aprrox. 9:00pm - 9:30pm
DISPLAY DIRECTOR (permit will be issued to the following)
Name: Sarah Harris Phone:
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 1" Floor Fax: 602-506-6402
Phoenix, Arizona 85003
For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766.

Parish
Rose Anthem
St. infofireworksaz.com
Pressurized Extinguishers Aerial
2-A Fire 2.5" 480-948-0090
Class Water Size:
2
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Arizona
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Site ILT=MEME= rrojuctions
Display Map
rireworks
Site

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

Daisy Mountain Fire Prevention
41018 N Daisy Mountain Drive Anthem Az. 85086 623-465-7400 August 14. 2018
Mrs. Harris,
Thank you for the submittal from Fireworks Production to conduct the fireworks display
for the St. Rose Philippine Duchesne Catholic Parish event and obtaining a DMFD permit
for this event. Your site, operator, and plan for the display is approved. A valid County
permit shall be obtained, DMFD standby and site inspection will be required on the day
of the event. We look forward to working with you again. Please let us know if you need
any further information.
Sincerely,
'23evire.
Dave Nielsen — Deputy Chief
Fire Prevention 623-465-7400

DAISYMOUNTAIN
41018 N DAISY MOUNTAIN DR
ANTHEM, AZ 85086
Permit Certificate DMFD
Date: 08/14/2018
Business Name: FIREWORKS PRODUCTION OF ARIZONA
Address: 17034 54TH ST
CHANDLER, AZ 85226
Phone: MAIN 480-948-0090
The following permit has been issued:
Permit No. 1819-038 Type: FIREWRKS FIREWORKS SALES/DISPLAY
Issued Date: 08/14/2018 OCCUPANT LOAD:
Effective Date: 10/13/2018
Expiration Date: 10/13/2018
Notes: DMFD standby and site inspection will be required on the day of the
event.
Fire works show at St. Rose Philippine Duchesne
2825 W. Rose Canyon Circle
Anthem Az 85086
Fireworks Production of AZ
17034 S. 54th Street
Chandler Az 85226
480-948-0090
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.
08/14/2018
Inspector:DMFD FIRE PREVENTION Date
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08/14/2018 15:49 Page

,--- 1 0
ACCWEP DATE (MM/DDNYYY)
CERTIFICATE OF LIABILITY INSURANCE
kr--- 7/12/2018
THIS 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: Cheri! Cruden
The Partners Group Ltd PHONE FAX
11225 SE 6th St., Suite 110 (A/C. No. Ext): 425-467-3151 (A/C, No): 425-455-6727
Bellevue WA 98004 ADDRESS: E-MAIL ccruden@tpgrp.COM
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: T.H.E. Insurance Company 12866
INSURED 16021 INSURER B:
FPA, LTD
Fireworks Productions of Arizona INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1125919118 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 VVITH 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR TYPE OF INSURANCE ADDL INSR SUBR VVVD POLICY NUMBER (MM/DDNYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS
A GENERAL LIABILITY Y CPP010586201 10/9/2017 10/9/2018 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 500,000
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ N/A
$2000 Deductible PERSONAL & ADV INJURY 1,000,000
GENERAL AGGREGATE $ N/A
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
—7 POLICY X MT- LOC $
A AUTOMOBILE LIABILITY CPP010586201 10/9/2017 10/9/2018 COMBINED SINGLE LIMIT
(Ea accident) $ 1,000 000
ANY AUTO BODILY INJURY (Per person) $
AUS ALL TO OVVNED AUTOS SCHEDULED BODILY INJURY (Per accident) $
X HIRED AUTOS AUTOS NON-OVVNED PROPERTY (Per accident) DAMAGE $
$
UMBRELLA LIAB X OCCUR ELP001232901 10/9/2017 10/9/2018 EACH OCCURRENCE $ 9,000,000
X EXCESS LIAB CLAIMS-MADE AGGREGATE $ 9,000,000
DED RETENTIONS $
A WORKERS COMPENSATION WCP0005328002 10/9/2017 10/9/2018 X WC STATU- OTH
AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER
ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? N / A EL. EACH ACCIDENT $1 ,000,000
(Mandatory in NH) EL. DISEASE - EA EMPLOYEE $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
The following are Additional Insured on General Liabi ity as their interest may appear as respects to operations performed by or on behalf of
the Named Insured, as required by written contract:
Date of Display: October 13, 2018
Location of Display: St. Rose Parish
Additional Insured(s): State of Arizona; Maricopa County; Daisy Mountain Fire District; St. Rose Philippine Duchesne.
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.
St. Rose Philippine Duchesne
2825 W. Rose Canyon Circle AUTHORIZED REPRESENTATIVE
Anthem AZ 85086
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD

Certificate of Fitness for Pyrotechnics
C Phoeni F ire
GREGORY HARRIS
NOT AFIRE DEPT EMPLOYEE

EXHIBIT A
St. Rose Philippine Duchesne Catholic Parish
Saturday, October 13, 2018
10 minute display
Total Aerial Effects 650
Total Shells 250 Total Effects in Basins 400
Opening:
The celebration of this special evening begins with a beautiful burst of fiery color.
10 – 2.5” Chinese Fancy Color Shells
Aerial Display:
A gorgeous assortment of brilliantly-colored shells, including Chrysanthemums,
Waves, Crowns, Peonies, Strobes, Diadems, and Crossettes in gorgeous Reds,
Yellows, Blues, Greens, Silvers, and Golds.
Your Aerial Display will contain a total of 200 aerial shells and 400 basin effects.
1 ½” - 4 FPA Premier Specialty Basin
2.5” - 200 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 40 aerial shells:
Your Grande Finale: 40 – 2.5” shells
Designed for St. Rose Philippine Duchesne Catholic Parish
by: Fireworks Productions of Arizona