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MAR1COPA 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: Anthem Name of Event: July 3rd., 2017 Fireworks Display Event Address: 41703 N. Gavilan Peak Parkway, Anthem, AZ. 85086 Date and Time of Event: July 3rd., 2017 @ 9:00 PM DISPLAY DIRECTOR (permit will be issued to the following) Name: Randy Reyman Phone: 602 -448 -1033 Business: Reyman Pyrotechniques/Any Pyro Fax: Address: 2937 N. 29th St., Phoenix, AZ. 85016 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 Certificate of Insurance 14024 Issue Date: 3/31/2017 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 Any Pyro INSURER B: DBA: Reyman Pyrotechniques 2937 N. 29th Street INSURER C: Phoenix, AZ 85016 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. 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. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE (DD/MM/YY) DATE (DD/MM)YY) A GENERAL LIABILITY PY/16-0176 1112212016 11/22/2017 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: 71312017 Location: Anthem Community Park Additional Insured: Anthem Community Council, Inc.; Anthem Parkside Community Association, Inc.; Anthem Country Club Community Association, Inc.; State of Arizona; Maricopa County. Purs.vapt to 4 rizow RPvised StAtutes-sePtiog 20-401 01 Rain Date(s): 7/3/2017 subsection B, paragraph 1; 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 inso vent insure Is or c aimants iv' not s e e igi e or insurance guaranty fund protection pursuant to A ri7ona Revised fitattieg title 20. 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, Inc. WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 3701 W. Anthem Way, Ste. 102 SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Anthem, AZ. 85086 „ -'9- 9 *Ir AUTHORIZED REPRESENTATIVE ANTHEM COMMUNITY PARK 41703 N. Gavilan Peak Pkwy. Fireworks fall out zone: Cars/people are prohibited I I in this area unless they have prior approval and are part of the event operations. • MINN OM • MMMMMMMMMMMMMMMMMM no••••••••• Launch site: This is where the fireworks are set up Skate •• and launched from. Only pyrotechnics and DMFD are Park, allowed in this area. • • asketba Middle Parking Lot • nd Vollayba a 1 Tennis Courts Soccer/ Multi•use Field fl 01;75 Lower Multi-use Parking Lot auriCil site NMI laid 2 Security Coverage areas = ProEm Security will have one person posted in ACC Maintenance Yard these locations during event hours. Parking lot en- (Restricted Access) trance starting at 4pm. All others members of the team will roam the park LEGEND Whitman Dr. = DBAK Security will always have one person at these areas during event hours. DBAK point of con. Ramadas tact will be first call made via radios and will dis- 1 Train 6 Sailboat 0 Playground patch from there to Posse and Deputies. All other 2 Bike 7 Baseball 0 Restroom Deputies will roam and shift to where needed. 3 Dock 8 Picnic G) Concessionifiestroom 4 Slide 9 Chair * Anthem Veterans Memorial = Posse will cover these areas , shifting to roadway 5 Apple 10 Main Pavilion - Daisy Mountain Railroad tracil duties when needed. anthem shells Reyman Pyrotechniques/Any Pyro Anthem Display, 7/3117 Content of display Following is the shell content of the display: 21/2 inch shells-42 3 inch shells-239 4 inch shells-180 5 inch shells-142 6 inch shells-12 Page./ 4 *. 4. n1iouLli Of Bo001 TeOmit: ins t ; Ili..mliqaton MEMBER ID: 369241 -RANDY L. REYMAN REYMAN PYROTECHNICQUES 41,0' ,M_74 City of Flagstaff Fire Department 211 W. Aspen Avenue *stir's:4 Flagstaff, AZ, 86001 -revrzre0 Pyrotechnics Permit Earn Permit Holder: Ranch/ Revman DL# Permit # 2,A,•20sZ2101-i032.31 DOE= — 2937 N. 29 St. ss#: Phoenix, AZ 85016 /7 Issued B y : Fire inspector Date Issued: IDENTIFICATION NAME _Randy L Reyrnan- 2937 N 29th St, Phoenix ADDRESS STATE M. D 0 8 THIS CERTIFICATE IS NOT TRANSFERABLE AND MAY BE REVOKED FOR-CAUSE NOT TO BE USED OUTSIDE CITY OF PHOENIX 9S-100D New 5107 Daisy Mountain Fire Prevention 515 E. Carefree Highway PMB #385 Phoenix Az, 85085 623-465-7400 April 06,2017 Mr. Reyman, Thank you for the notification that Reyman Pyro-techniques/Any Pyro will be conducting the firework display for the Anthem's July 3rd, 2017 event and getting a DMFD permit for this event. As in the past, once you have the required County permits, DMFD will complete the permit process. This site is approved (requires day of setup inspections) and we look forward to working with you again. Please let us know if you need any further information. Dave Nielsen, Divva Nz-ette4A. Fire Prevention Division Chief Fire.Marshal@dniffd.org 623-465-7400 U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Federal Explosives Licensing Center 244 Needy Road Martinsburg, West Virginia 25405 901090: CRR/FLS 5400 File Number 9AZ03233 08/05/2016 SUBJECT: RESPONSIBO.,PERSONUTTER OF CLEARANCE for: rit.ANDOLPH LEE REV MAN OWNER • 2937; N ..9T1-1 ST , • P1-10Nk, AZ 85016 and is ONLY1Talid under, the followingifederd explosives license/permit: 9-AZ-013-21-9403233 'REYMAN, RANOY REYMAN PYROTEC14114:0ES/ANY PYRO 2937 N 29TH STREET 1) PHOENIX, AZ 8501 .6,: Dear RANDOLPH REYMAN: You have been approved as a responsible person under the above-listed Federal explosive license or permit. You may lawfully direct the management or policies of the business or operations as they pertain to explosives. You may also lawfully transport, ship, receive or possess explosive materials incident to your duties as a responsible person. This clearance is only valid under the license or permit referenced above. Sincerely, CilitAl5/10//t9'( /C. le-e.e1-9 Christopher R. Reeves Chief, Federal Explosives Licensing Center (FELC) FELC Customer Service. If you believe that information on your "Letter of Clearance" is incorrect, please return a COPY of the letter to the Chief, Federal Explosives Licensing Center (FELC), with a statement showing the nature of the error, The Chief, FELC, shall correct the error, and return an amended letter to you, Mail: ATF Fax: 1-304-616-4401 Call toll-free: 1-877-283-3352 Chief, FELC Chief, FELC Attn.: LOC Correction Attn.: LOC Correction 244 Needy Road Martinsburg, West Virginia 25405 AZ03233.R.08105/20,5 .AEYMAN•RANDOLPH.LEE OWNER WWW.ATEGOV Department of Justice v.-44. vv. .M.1./101, Is, A V Vle .M.AStdSAh.Y%.J S Vfir. A ASA I II, eau of Alcohol, Tobacco, Firearms and Explosives (18 U.S.C. Chapter 40) 111111111111119111111 1 111111113111111 1119111 •11111111 cordance with the provisions of Title XI, Organized Crime Control Act of 1970, and the regulations issued thereunder (27 CFR Part 555), you may engage in ictivity specified in this license or permit within the limitations of Chapter 40. Title 18. United States Code and the regulations issued thereunder, until the ration date shown. THIS LICENSE IS NOT TRANSFERABLE UNDER 27 CFR 555.53,, See "WARNINGS" and "NOTICES" on reverse. !et ATF ATF - Chief, FELC License/Permit :espondence To 244 Needy Road Number 9-AZ-013-21-9H-03233 Martinsburg, WV 25405-9431 e, Federal E' losives Licensing Center (FELC 12zeirs Expiration Date August 1, 2019 REYMAN PYROTECHNIQUES/ANY PYRO 'emises Address (Changes? Notify the FELC at least 10 days before the move.) 2937 N 29TH STREET PHOENIX, AZ 85016- e of License or Permit 21-MANUFACTURER OF EXPLOSIVES Purchasing Certification Statement Mailing Address (Changes? Notify the FELC of any changes.) licensee or pennittee named above shall use a copy of this license or peimit to assist a feror of explosives to verify the identity and the licensed status of the licensee or 'Mee as provided by 27 CFR Part 555. The signature on each coov must be an oriainal am. A faxed, scanned or e-mailed copy of the license or permit with a signature REYMAN, RANDY ded to be an original signature is acceptable. The signature must be that of the Federal REYMAN PYROTECHNIQUES/ANY PYRO osives Licensee (FEL) or a responsible person of the FEL,. I certify that this is a true 2937 N 29TH STREET of a license or permit issued to the licensee or pennittee named above to engage in the less or operations specified above under "Type of License or Permit." PHOENIX, AZ 85016- msee/Permittee Responsible Person Signature Position/Title Printed Name. • Date MP Form 5400.14/5400.1:5 Pan I ous Edition is Obsolete NYMAN. NAN DY2137 N 251H 51115511.5016.1741.019.211N•03233Ausuti I. 2012:2141ANUFACTUPIR OF EXPLOSIVES Revised October 2011 Federal Explosives License (FEL) Customer Service Information :ral Explosives Licensing Center (FELC) Toll-free Telephone Number: (877)283-3352 ATF Homepage: www.atlgov Needy Road Fax Number: (304) 616-4401 tinsburg, WV 25405-9431 E-mail: FELC@atf gov nge of Address (27 CFR 555.54(a)(1)). Licensees or permittees may during the term of their current license or permit remove their business or operations to a location at which they intend regularly to carry on such business or operations. The licensee or pennittee is required to give notification of the new location of the ness or operations not less than 10 days prior to such removal with the Chief, Federal Explosives Licensing Center. The license or permit will be valid for the tinder of the term of the original license or permit. (The Chief, FELC, shall, if the licensee or permittee is not qualified, refer the request for amended license ermit to the Director of Industry Operations for denial in accordance with § 555.54.) at of Succession (27 CFR .555.59). (a) Certain persons other than the licensee or permittee may secure the right to carry on the same explosive materials ness or operations at the same address shown on, and for the remainder of the term of, a current license or permit. Such persons are: (1) The surviving spouse or executor, administrator, or other legal representative of a deceased licensee or permittee; and (2) A receiver or trustee in bankruptcy, or an assignee for :fit of creditors. (b) In order to secure the right provided by this section, the person or persons continuing the business or operations shall furnish the license or lit for for that business or operations for endorsement of such succession to the Chief, FELC, within 30 days from the date on which the successor begins to on the business or operations. : Here X (Continued on reverse side) Federal Explosives License/Permit (FEL) Information Card cense/Permit Name: REYMAN, RANDY .isiness Name: REYMAN PYROTECHNIQUES/ANY PYRO cense/Permit Number: 9-AZ-013-21-9H-03233 cense/Permit Type: 21-MANUFACTURER OF EXPLOSIVES :piration: August 1,2019 ase Note: Not Valid for the Sale or Other Disposition of Explosives.