BOULDER CREEK HIGH SCHOOL 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: Boulder Creek High School
Name of Event: Football Fireworks
Event Address: 40404 N Gavilan Peak Parkway, Anthem AZ 85086
Date and Time of Event: October 27, 2017 @ aprrox. 6:45pm - 10:00pnn
DISPLAY DIRECTOR (permit will be issued to the following)
Name: Sarah Harris Phone
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

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

A/LEM:AA
BONDING COMPANY.
mEkCHAXTS BOKDING 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 411797
KNOW ALL PERSONS BY THESE PRESENTS, that we
FPA, LTD. dba FIREWORKS PRODUCTIONS OF ARIZONA
as Principal, and MERCHANTS BONDING COMPANY (MUTUAL), a corporation
organized under the laws of the State of Iowa, and duly authorized and
licensed 7.o MARICOPA do i.Y,]siness COUNTY in the S7:_ate of Arizona, as Surety, are firmly
bound unto
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. dbaHREWORKS PRODUCTIONS
WHEREAS the above bounden Principal OFARIZEINA
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 OneThousandDollars
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.
EPA, 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,
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,
eOisiaOi:re Session Laws of 1941, for a period from 12:01 A.M.
August23,2017 to 12:01 A.M. August 23, 2018 then this
obligation to be void, and of no effect.
SIGNED, sealed and dated this 15th day of August 2017
FPA, LTD. dba FIREWORKS PWODUCTIONS OF
ARIZONA
Principal
MERCK VI (BON_DING COMPANY (MUTUAL)
By
Attorney-in-fact Debi Williams
LP 0265 AZ (2/15)

Daisy Mountain Fire Prevention
515 E. Carefree Highway PMB #385 Phoenix Az 85085 623-465-7400 September 12,2017
Thank you for the application from Fireworks Productions of AZ which will be
conducting a firework display/show for the Boulder Creek football event on Oct. 27th
2017. Your site, operator, and display plan is approved and DMFD has issued permit
#000769 for this event. A valid County permit shall be obtained and DMFD standby
personnel 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,
Devve, ni,d4-e4ii
Dave Nielsen - Division Chief
Fire Prevention 623-465-7400
www.DasiyMountainFire.org

HUGH DERING
FIREWORKS PRODUCT1C
7/14/201.8
suscended for any nmsuse C ne ca. The c.3c. s
the City of Phoenix and shad be surrendered uocc -ecuest ry4
local government or federal agency.
The card identifies but does not recomr - e - c. t - e - : - er The Cit y
of Phoenix assumes no !iabil.ity for activities +.hoz
cardholder.
Cardholder slarail/e
re Marsnal
2/24/2016

EXHIBIT A
BOULDER CREEK HIGH SCHOOL
Anthem
Friday, October 27, 2017
SENIOR NIGHT/HOMECOMING
Total Aerial Effects 92
Boulder Creek High School's Homecoming will contain a multitude of fantastic
shells in beautiful colors to celebrate this year's homecoming and Royal Court.
Aerial Display:
A large assortment of brilliantly-colored shells, including Chrysanthemums, Crowns,
Peonies and Diadems in gorgeous Reds, Yellows, Blues, Greens, Silvers, and Golds.
Your Aerial Display will contain a total of 85 aerial shells shot during important moments
of the evening to excite the home crowd and celebrate the Jaguars' accomplishments.
2.5" - 92 Chinese Fancy's & Specials
Boulder Creek High School's show to consist of:
TEAM INTRO: 14 — 2.5" Aerial Shells
NATIONAL ANTHEM:
3 - 2.5" Red Aerial Shells for "Rockets Red Glare"
3 - 2.5" Aerial Shells for "Bombs Bursting"
7 - 2.5" Aerial Shells at the end
SCORE SHELLS: 3 - 2.5" Aerial Shells each Touchdown or Field Goal (30 Total)
KING & QUEEN (HALFTIME): 14 - 2.5" Aerial Shells
TEAM INTRO AT END OF HALF-TIME: 7 - 2.5" Aerial Shells
END OF GAME: 14 - 2.5" Aerial Shells
(Any remaining Score Shells shot at end of game)
Desned for 5oulder Creek th:gh 5chool by: Fireworks Productions of Arizona

-- T 0
AC'ORE) DATE (MM/DDPNYY)
CERTIFICATE OF LIABILITY INSURANCE
4.....----- 9/1212017
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 FAX
11225 SE 6th St., Sui te 110 talc E-MAIL No EA:425-467-3151 (NC, No):425-455-6727
Bellevue WA 98004 ADDREss:ccruden@lpgrp.com
INSURER(S) AFFORDING COVERAGE NAIC #
iNsuRERA:T.H.E. Insurance Company 12866
INSURED 16021 INSURERS:
FPA, LTD INSURER C :
Fireworks Productions of Arizona
INSURER D :
17034 S. 54th Street
Chandler AZ 85226 INSURER E :
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1425681023 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 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 (MM/DD/YYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS
A GENERAL LIABILITY Y CPP010586201 0/9/2017 10/912018 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE PREMISES TO (Ea RENTED occurrence) $500,000
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ NIA
$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
POLICY X INT- LOC $
AUTOMOBILE LIABILITY CPP010586201 10/9/2017 1019/2018 COMBINED (Ea accident) SINGLE-MIT $1,000,000
ANY AUTO BODILY INJURY (Per person) $
ALL AUTOS OWNED AUTOS SCHEDULED BODILY INJURY (Per accident)
X HIRED AUTOS AUTOS NON-OWNED PROPERTY (Per accident) DAMAGE $
$
UMBRELLA LIAB X OCCUR ELP001232901 10/9/2017 10/9/2018 EACH OCCURRENCE $9,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000
DED RETENT ON $ $
WORKERS COMPENSATION WCP0005328002 10/9/2017 10/9/2018 X WC STATU- 0TH-
AND EMPLOYERS' LIABILITY Y / N TORY LIMITS ER
ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? N IA EL EACH ACCIDENT $1,000,000
(Mandatory in NH) EL. DISEASE - EA EMPLOYEE $1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below EL 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 Liability 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 27, 2017
Location of Display: Boulder Creek High School, Anthem, AZ
Additional Insured(s):State of Arizona; Maricopa County; Daisy Mountain Fire District; Deer Valley Unified School District #97; Boulder Creek
High School; Boulder Creek Football Foundation.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Deer Valley Unified School District #97 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
18424 N. 51st Avenue ACCORDANCE WITH THE POLICY PROVISIONS.
Glendale AZ 85308
AUTHORIZED REPRESENTATIVE
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD

HS
Creek AZ
Anthem,
Boulder
info@fireworksaz.corn
Pressurized Ertingbishers Shells
2-A Fire 2.5"
Class 2 Water
Size:
480-948-0090
Shells
Maximum
Arizona
of
Productions
Map Fireworks
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