NORTHWEST CHRISTIAN SCHOOL PROM FIREWORKS 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,
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: Northwest Christian School
Name of Event: Prom Fireworks
Event Address: Anthem Golf & CC @ 41551 N Anthem Hills Dr Anthem AZ 85086
Date and Time of Event: April 21, 2018 @ aprrox. 8:15pm
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: 17034 S 54th Street, Chandler AZ 85226 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)
email to Clerk of the Board

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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

MERC TS
BONDING COMPANY.
MERCNABONDING COMPANY (MUTUAL) P.O. BOX 14498, DES MOINES, IA 50306-3498
PHONE: (800) 678-8171 FAX: (515) 243-3854
FIREWORKS DISPLAY BOND
Bond No. AZ 41] 797
KNOW ALL PERSONS BY THESE PRESENTS, that we
FPA, LTD. dba FIREWORKS PRODUCTIONS OF ARIZONA
as Principal, and MERCHANTS BONDING COMPANY (MUTUAL), a corporation
ore-anized under the laws of the State of Iowa, and duly authorized and
') cerse-ti - c 'n of Arizona, as Surety, are firmly
bound unto MARICOPA COUNTY
State of Arizona
in the sum of One Thousand Dollars DOLLARS ($$1,000.00
lawful money of the United States, to the payment of which sum, well and
truly to be made, the Principal and Surety bind themselves, their and each
of their heirs, executors, administrators, successors and assigns, jointly
and severally, firmly by these presents.
FPA,LTD. dba FIREWORKS PRODUCTIONS
WHEREAS the above bounden Principal OF ARIZONA
desires to have a permit for Fireworks Display and in order to have such
display it is necessary for said FPA, LTD. dba FIREWORKS PRODUCTIONS OF
ARIZONA
to execute a surety bond in the amount of One Thousand Dollars
Dollars ($ $1,000.00 ) conditioned for the payment of all damages which may
be caused to persons or property by reason of the permitted display as
provided in Chapter 46, Arizona Legislative Session Laws of 1941.
FPA, LTD. dba FIREWORKS PRODUCTIONS OF
NOW, THEREFORE, if the said ARIZONA
well and truly observe, carry out, perform and comply with all requirements,
terms and provisions of the Ordinances of the Board of Supervisors of
MARICOPA COUNTY County, State of Arizona,
condit ioned for the payment of all damages which may be caused to persons or
cpfon=,:rtv by reason of the permitted display as provided in Chapter 46,
Eessccr Thaws of 1941, for a period from 12:01 A.M.
August 2 3 2 0 1 7 tl'o 12:01 A.M. August 23, MI8 then this
obligation to be void, and of no effect.
SIGNED, sealed and dated this 15th day of August 2017
FPA, LTD. dba FIREWORKS FlODUCTIONS OF
ARIZONA I 1
Principal
MERCHAW BONDING COMPANY (MUTUAL)
By
Attorney-in-fact Debi Williams
065 AZ (2/15)

.-- 1 0
ACC)REP DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
L.------ 2/26/2018
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: Cheril Cruden
The Partners Group Ltd PHONE Exu: 425-467-3151 FAX (Arc, No): 425-455-6727
11225 SE 6th St., Suite 110 (A/C, No,
Bellevue WA 98004 ADDRESS: E-MAIL ccruden@tpgrp.COM
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: T.H.E. Insurance Company 12866
iNsuaso 16021 INSURER B:
FPA, LTD
Fireworks Productions of Arizona INSURER C:
17034 S. 54th Street INSURER 0:
Chandler AZ 85226 INSURER E:
INSURER F:
COVERAGE CERTIFICATE NUMBER: 321100025 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. NOTVVITHSTANDING 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER IMMIDDfYYYY) POLICY EFF IMM/DDIYYYY) POLICY EXP LIMITS
A GENERAL LIABILITY Y CPPO 0586201 10/9/2017 101912018 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
GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY X FJNi LOC
A AUTOMOBILE LIABILITY CPP010586201 10/9/2017 10/9/2018 COMBINED (Ea ac,cident) SINGLE LIMIT $ 1,000 000
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED — y SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X NON-OWNED PROPERTY DAMAGE $
X HIRED AUTOS AUTOS (Per accident)
$
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 RETENTION $ $
A WORKERS COMPENSATION VVCP0005328002 10/9/2017 10/9/2018 X TORY WC STATU- LIMITS 0TH ER -
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N / A
(Mandatory in NH) E.L. 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: April 21, 2018
Location of Display: Anthem Golf & Country Club
Additional Insured(s): State of Arizona; Maricopa County; Daisy Mountain Fire District; Anthem Golf & Country Club; Northwest Christian School; Association of
Christian Schools International; North Central Association of Colleges and Schools.
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.
Anthem Golf & Country Club
41551 North Anthem Hills Dr 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

EXHIBIT A
NORTHWEST CHRISTIAN SCHOOL
NEJS
Saturday, April 21, 2018
1•7 1111 .0 % . - INI
PROM
3 —4 minute display
Total Aerial Shells 100
Northwest Christian School's Prom display will contain a multitude of fantastic
shells in beautiful colors to celebrate this year's students and Royal Court.
Opening:
Your show begins with an impressive series of powerful booms and flashing
color to excite and thrill the audience.
7 - 3" Chinese Fancy's Color Shells
Aerial Display:
A large assortment of brilliantly-colored shells, including Chrysanthemums, Waves,
Crowns, Peonies, Strobes, Brocade Crowns, Diadems, and Crossettes in gorgeous
Reds, Yellows, Blues, Greens, Silvers, and Golds.
Your Aerial Display will contain a total of 72 aerial shells.
3" - 72 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 21 aerial shells:
Desgnec/ for Northwest Christian 5cAool by: Fireworks froductions ol Arizona

Certificate of Fitness for
GREGORY HARRIS
ireworks Productions of Az
/11/2019

Daisy Mountain Fire Prevention
41018 N Daisy Mountain Dr. Anthem Az. 85085 623-465-7400 March 5,2018
Daisy Mountain has received an application from Fireworks Productions, which will be
conducting a firework display/show at the Anthem Golf and Country Club event on
April 21, 2018. Your site, operator, and display plan is approved and DMFD has issued
permit #1718-187 for this event. A valid County permit shall be obtained and DMFD
stand-by personnel will be required on the day of the event. Please let us know if you
need any further information.
Sincerely,
Davve,
Dave Nielsen Nielsen — Division Chief
Fire Prevention 623-465-7400

Daisy Mountain Fire District Phil Dyer
515 E. Carefree Hwy, PMB #385 Captain
Phoenix, Arizona 85085 Fire Marshal
Phone: (623) 465-7400 Fire.marshall®DaisyMouniainFire.org
Fax: (623)465-7632
PLAN / PERMIT APPLICATION
Application:
Application for a permit required by this code shall be made to the fire code official in such form and detail as prescribed
by the fire code official. Applications for permits shall be accompanied by such plans as prescribed by the fire code
official.
Types of permits:
There shall be two types of permits as follows:
I. Construction permits. A construction permit allows the applicant to install, build or modify systems and equipment.
2. Operational permit. An operational permit allows the applicant to conduct an operation or a business.
Time limitation of application:
Permit period for any proposed work shall be six months after the date of filing.
Posting permits.
Issued permits shall be kept on the premises designated therein at all times and shall be readily available for inspection by the
lire code official.
PROJECT INFORMATION:
Date Submitted: 02 / 28 / 18
Street Address: 41551 N Anthem Hills Dr.
TYPE OF PERMIT: (Indicate one) Nearest Cross Street: W. Anthem Way
CONSTRUCTION: City: Anthem State: AZ
Fire Alarm: 0 Fire Sprinkler: 0 Site Name: Anthem Golf & Country Club
Fire Line: 0 Extinguishing System: 0 OWNER INFORMATION:
Compressed Fuel Gas Tank: 0 Remove
Tenant Improvements: 0 Knox Box 0 Name: Anthem Golf & Country Club
Contact Person: Kathy Cuaderno
BUILDING/SITE PLAN REVIEW: 0 Address: 41551 N Anthem Hills Dr
0 Other: City: Ant hem State: AZ zip: 85086
Telephone:
OPERATIONAL: APPLICANT INFORMATION:
Carnival / Fair: 0 Exhibit / Trade Show: Company: Fireworks Productions of AZ
Fueled Vehicles in Buildings: 0 Address: 17034 S. 54th Street
Pyrotechnic Special Effects: 0 City: Chandler State: AZ zip: 8 52 2 6
Open Flames/Candles: 0
Temporary — Membrane/Tents/Canopy: 0 Contact: Sarah Harris
Fireworks Display Telephone: ( 480 ) 948 - 0090
d ottier: Fax: ( 4 8 0 ) 423 _ 5430
Number of Plans Submitted: - 1
Description of Project: Fireworks Display for Northwest Christian School Prom
DMFD STAFF USE ONLY: Application Review by: Date Received: 3- -TS
Reviewed by: Date approved: 3- t Permit / Review #: i1 it -
Copy submitted to Accounting Department: 0 NO — There are no fees at this time. YES — Fee information is attached.
ACCOUNTING: Received by Invoice Date: Invoice /4 . 1718 -1b7 - 4.D.SciP
NOTIFICATION: Date Applicant Notified: 3-5 -
PERMIT ISSUED: Picked up by Phone #: Date
PAYMENT: $ 0 Cash 0 Check - 4 Comments: