ST. ROSE PHILIPPINE DUCHESNE CATHOLIC PARISH REDACTED.PDF

MARICOPA COUNTY BOARD OF SUPERVISORS
301 West Jefferson, 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, Phoenix, 85003
(602-506-2774) at least 30 days prior to the event date.
Include the following items with your application:
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.
NAMBORGANIZATION St. Rose Philippine Duchesne Catholic Parish
EVENT ADDRESS 2825 W. Rose Canyon Circle, Anthem AZ 85086
DATE AND TIME OF EVENT October 14, 2017 @ approx. 9:00pm - 9:30pm
DISPLAY DIRECTOR (permit will be issued to the followinp)
Name: Sarah Harris Phon
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address: 17034 S. 54th Street, Chandler AZ 85226 Email:
SHERIFF'S OFFICE RECOMMENDATION
The State Fire Marshal has inspected 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 filed pursuant to A.R.S. § 36-1603, together with proper bond as provided by law, and having been
approved by the State Fire Marshall and Sheriff, 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.
DATED this day of 20
Clerk of the Board, authorized signature

MERC A TS \
BONDING COMPANY,.
MERCHANTS BONDING 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 to do business in the State 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 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.
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,
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, for a period from 12:01 A.M.
August 23, 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 PIMUCTIONS OF
ARIZONA
MERC(HOITA BONDING COMPANY (MUTUAL)
By
Attorney-in-fact Debi Williams
LP 0265 AZ (2/15)

Daisy Mountain Fire Prevention
515 P. Carefree Highway PM13 #385 Phoenix Az. 85085 623-465-7400 August 21.2017
Thank you for the application from Fireworks Productions of AZ which will be
conducting a firework display/show for the St. Rose Phillippine Duchesne in Anthem on
October 14th 2017. Your site, operator, and display plan is approved and DMFD has
issued permit #000761 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,
DOW* n1,&6eA1,
Dave Nielsen - Division Chief
Fire Prevention 623-465-7400

Phoenix Certificate of Fitness
Troy Wolek
Head Pyrotechnician
Certificate of Fitness for Pyrotechnics
c.C40);
TROY WOLEK
FIREWORKS PRODUC110
Certificate of fitness is not transferable and may be revoked and or
suspended for any misuse of the card. The card is the property of
the City of Phoenix and shall be surrendered upon request by any
local government or federal agency.
The card identifies but does not recommend the bearer. The City
of Phoenix assumes no liability for activities performed by the
cardholder.
?n,
Cardholder signature
Fire Marshal
Fireworks Productions of Arizona
1-877-948-0090...info@fireworksaz.com

EXHIBIT A
St. Rose Philippine Duchesne Catholic Parish
Saturday, October 14, 2017
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 1/2" - 4 EPA 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
Des&nec i for5t Kose Philippine Duchesne Catholic fariSh
by: Fireworks froductions of Arizona

--- 1 0 DATE (MM/DDIYYYY)
ACC)1?f, CERTIFICATE OF LIABILITY INSURANCE
C ..,,,I-• 8/16/2017
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: Janet Nau
The Partners Group Ltd LAIC. FlHONE No, Ext):425-455-5640 FAX (NC, No:425-455-6727
11225 SE 6th St., Suite 110 E-MAIL
Bellevue WA 98004 ADDRESS:Jnau(Stpgrp.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A T.H.E. Insurance Company 12866
INSURED INSURER B :
Fireworks Productions of Arizona INSURER C:
17034 S. 54th Street INSURER D :
Chandler AZ 85226 INSURER E :
INSURER F:
COVERAGES CERTIFICATE NUMBER: 1040558720 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 ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMM/DDNYYY) (MM/DD/YYYYI
A GENERAL LIABILITY Y CPP010586200 1019/2016 10/9/2017 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
$2,000Deductible PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $N/A
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGO $2,000,000
7 POLICY X FJ78-i LOC $
AUTOMOBILE LIABILITY CPP010586200 10/9/2016 10/9/2017 COMBINED (Ea accident) SINGLE LIMIT $1,000,000
BODILY INJURY (Per person) $
ANY AUTO
ALL OWNED X SCHEDULED BODILY INJURY (Per accident)
AUTOS ../ AUTOS NON-OWNED PROPERTY DAMAGE
X HIRED AUTOS " AUTOS (Per accident)
$
UMBRELLA LIAB _ X OCCUR Y ELP001232900 10/9/2016 10/9/2017 EACH OCCURRENCE $9,000,000
—
EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000
DED RETENTION $
WORKERS COMPENSATION WCP0005328001 10/9/2016 10/9/2017 X TORY WC STATU- LIMITS 0TH- ER
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE EL. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $1,000,000
If DESCRIPTION yes, describe under 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 14, 2017
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
St. Rose Philippine Duchesne THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
2825 W. Rose Canyon Circle ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem AZ 85086
AUTHORIZED REPRESENTATIVE
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

Parish
Rose Anthem
St. info@fireworksaz.coni
Pressurized Extinguishers Aerial
2-A 2.5" 480-948-0090
Fire
Class Water go* Size:
1 2 tit)0 611.
b k Shell
1%*
iisfip Maximum
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