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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 followin g 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: la) t.t -NI evV1 Name of Event: Ci-1/4 ,1 4) zoo ..c..wej.0.3(v. m s,,56\ 0,:_i Event Address: 44'1103 NI- Goof. a_ PaSILOCL4 i fintitito, Az. B .o.c, Date and Time of Event: ^0-1k94.4 .., 20 12 ' DISPLAY DIRECTOR (permit will be issued to the following) 021111MIEMMIIIMM11111111111111111111111 Phone: 0)1 —W.' 033 Business: 'Re Fax: Address: 1E:1 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. 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 16503 Issue Date: 1/25/2018 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 Novato, California 94949 AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED INSURER A: Underwriter's at Lloyd's, London Randy Reyman INSURER B: DBA:Any Pyro DBA: Reyman Pyrotechniques 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. NOTWI1HSTANDING 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) I A GENERAL LIABILITY PY/17-0192 11/22/2017 11/22/2018 EACH ACCIDENT $1,000,000 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: 7/3/2018 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. ' t . vised Statutes-segtion--2-04BLAL,, Rain Date(s): 7/3/2018 subsection B, paragraph I; 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 Type of Display: Aerial Fireworks Display insolvent, insureds or claimants will not be eligible for insurance guaranty fund protection pursuant to AlIZEIMI R4.144,.-04442444.p,kt-tit3it 'NI 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 WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 3701 W. Anthe m Way Ste. 102 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Anthem, AZ. 85086 ir AUTHORIZED REPRESENTATIVE ANTHEM COMMUNITY PARR 41703 N. GayNan Peak Pkwy0 Fireworks fail out sore: Cars/people are prohibited in this area unless they have prior approval and are part of the event operations. If Pit I III NI I PI M PRIMP M IM DI Launch site: This is where the fireworks are set up fikAts, NI and launched from, Only pyrotechnics and DMFD are • fk allowed in this area. • Nol•••••••••••••••••••••••••••01 atkattia :Pcialdn9 L6t fatuicar- - -‘• -1-etri ,-- sotto/ I / iiinellit9 Fiac _ d ' 13 a , /MK Two ir-LeT7T-11 i Satcar/ 1 ' ,Whitikaa Mid ititi ..z. arinrE it — 1 Security Coverao areas = ProEm Security will have one person posted in la -Idolatanancalfard these locations during event hours. Parking lot en- tRaAticted'AmP40- trance starting at 4pm. All others members of the team will roam the park Ifigtman Dr. END DBAK Security will always have one person at these areas during event hours. DBAK point of con. ;amadag tact will be first call made via radios and will dis- rvi1 6 5Mboat Filnywom patch from there to Posse and Deputies. All other 3itta 7ga5d,,,a10 0:31 noowoogn )tutt 8 Pio• Con_cos.(3i ou/Hogtovorm Deputies will roam and shift to where needed. ;Me 9 ChAir VOell'atm movio 0 Posse will cover these areas , shifting to roadwa igTga MAW avinon Dahy flittmotoi0 Mileoad trac duties when needed. 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 anthem shells Reyman Pyrotechniques/Any Pyro Anthem Display, 7/3/18 Content of display Following is the shell content of the display: 2 1/2 inch shells-42 3 inch shells-239 4 inch shells-180 5 inch shells-142 6 inch shells-12 Page 1 _ AnienuojulA kissotriaiAon f)f U4144J, 'Poolinitutitus XivroNtiffators MEMBER ID: 'RANDV REYMAN REYMAN PYROTECHNICQUES 1 1 1 1 1 1 1 1 1 1 II 1 1 1 1 1 1 1 ASSOCIATE Region: City of Flagstaff Fire Department 211 W. Aspen Avenue Flagstaff, AZ, 86001 Pyrotechnics Permit Applicant: Randy Revm an Permit Holder: DLO Permit DOB: ligm. s so: Issued BY: _120/i , Fire Inspector , , Date Issued: -) 04 Daisy Mountain Fire Prevention 41018 N Daisy Mountain Dr. Anthem Az. 85085 623-465-7400 April 12,2018 Daisy Mountain has received an application from Any Pyro which will be conducting a firework display/show for the Anthem 3rd of July event on July 3 1d, 2018. Your site, operator, and display plan is approved and DMFD has issued permit #1718-224 for this event. A valid County permit shall be obtained and DMFD standby personnel will be required on the day of the event. Please let us know if you need any further information. Sincerely, Detrit& 711;&6&01, Dave Nielsen — Division Chief Fire Prevention 623-465-7400 ountair