BOULDER CREEK HIGH SCHOOL -REDACTED.PDF

Clerk of the Board of Supervisors
Maricopa County |
301 W. Jefferson
|
Phoenix, AZ. 85003
To Whom It May Concern:
Attached is the permit application for Boulder Creek High School
homecoming fireworks scheduled for October 14, 2016. I have also included
a copy of the letter from Dave Nielsen of Daisy Mountain Fire Department
since they will be the responding Fire Department.
Once the permit has been approved with Maricopa County Board of
Supervisors please send me a copy either by mail or email to the following
address:
Fireworks Productions of Arizona
Attn: Sarah Harris
17034 S. 54" Street
Chandler, AZ. 85226
sarah@fireworksaz.com
If you have any questions or need any additional information please do not
hesitate to contact my office. Thank you very much!
Pyrotechnically Yours,
Sarah Harris
Pyro Office Manager
’ Pyrotechnician
17034 S. 54th Street » Chandler, Arizona 85226 » office (480) 948-0090 « fax (480) 423-5430 = toll free 1-877-948-0090
e-mail: info@fireworksaz.com * web: www.fireworksaz.com

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.
NAME\ORGANIZATION | Boulder Creek High School
EVENT ADDRESS | 40404 N. Gavilan Peak Parkway, Anthem AZ 85086
DATE AND TIME OF EVENT | October 14, 2016 @ approx. 6:45pm - 10:00pm
DISPLAY DIRECTOR (permit will be issued to the followin
Name: Sarah Harris Phone:
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address: 17034 Ss. 54" Street, Chandler AZ 85226 Email:
sarah@fireworksaz.com
1/04] 1
3
Signature Date
oA DinplenDisctan,
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

MERCHANTS SS,
BONDING COMPANY.
MERCHANTS BONDING COMPANY (MUTUAL) P.O. BOX 14498, DES MOINES, 1A 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 business in the State of Arizona, as Surety, are firmly
mic RICOP >A COUNTY
bound unto
State of Arizona
in the sum of One Thousand Dollars DOLLARS ($351,000.00 \
lawful money of the United States, to the payment of which sum, well and
truly to be made, the Principal and Surety bind themselves, their and each
of their heirs, executors, administrators, successors and assigns, jointly
and severally, firmly by these presents.
FPA, LTD. dba FIREWORKS PRODUCTIONS
WHEREAS the above bounden Principal OF ARIZONA
desires to have a permit for Fireworks Display and in order to have such
it is for sa id FPA, LTD. dba FIREWORKS PRODUCTIONS OF
display necessary
ARIZONA
to execute a surety bond in the amount of One Thousand Dollars
Dollars ($ $1,000.00 }) conditioned for the payment of all damages which may
be caused to persons or property by reason of the permitte ed 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, 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, 2016 to 12:01 A.M. August 23, 2017 then this
obligation to be void, and of no effect.
SIGNED, sealed and dated this Ist day of June 2016
,
FPA, LTD. dba PROQUCTIONS OF
FIREWORKS
ARIZONA -.
Principal
i
= (MUTUAL)
ue
By
Attornéy-in- ig ing
as,
LP 0265 AZ (2/15)

Mountain Fire Prevention
Daisy
Sept. 9, 2016
Mrs. Harris,
Thank for the notification that Fireworks Productions of Arizona will be
you
the fireworks display for the Boulder Creek High Schools
conducting
Eaotball Homecoming event in Anthem on October 14in, 2016. As in the
once you have the required County permits, you can apply to the
past,
Daisy Mountain Fire District for a site permit, inspection and stand-by units.
The preliminary site map you have submitted has been approved and when
the event is closer we would like to do a pre-site visit with your staff. We
look forward to working with you again. Please let us know if you need any
further information.
Respectfully,
D.Niclren
Dave Nielsen
Fire Prevention Division Chief
Fire.Marshal@dmfd.org

EXHIBIT A
BOULDER CREEK HIGH SCHOOL
Anthem
Friday, October 14, 2016
HOMECOMING
Total Aerial Effects 85
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” - 85 Chinese Fancy’s & Specials
Boulder Creek High School’s show to consist of:
TEAM INTRO: 7 — 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)
Designed for Boulder Creek leh School by: Fireworks Productions of Arizona

®
|
@ DATE (MMI/DDIYYYY)
ACCORD CERTIFICATE OF LIABILITY INSURANCE
9/9/2016
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
Britton Gallagher PHONE | FAX
£4n:216-658-7100 nan ara. {AEnos
One Cleveland Center, Floor 30 A
1375 East 9th Street ADDRESS:
Cleveland OH 44114 INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :Everest National Insurance Company 10120
INSURED INSURER B :Maxum Indemnity Company 6743
INSURER C :Everest Indemnity Insurance Co. 10851
Fe MG
ath St
INSURER D :Travelers Property Casualty Co. of
Chandler AZ 85226
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 2110743551 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 ADDL|SUBR POLICYEFF | POLICY EXP
LIR TYPE OF INSURANCE INSR| WVD POLICY NUMBER (MMIDDIVYYY) | (MM/DDIVYYY) LIMITS
C | GENERAL LIABILITY Y $18ML00014-161 40/9/2016 10/9/2017 | EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
X | COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $500,000
| CLAIMS-MADE OCCUR MED EXP (Any one person) $
PERSONAL & ADVINJURY _| $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $2,000,000
pouicy [X_| RO: LOC $
A | AUTOMOBILE LIABILITY Y S18GA00008-161 torsizo1e | 10/9/2017 | GOMBINEDSINGLE LIMIT | 31 900,000
X | ANY AUTO BODILY INJURY (Per person) | $
ALL ALL OWNED |_| SCHEDULED BODILY INJURY (Per accident) ; | $
OM SoHee
x __| NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
B UMBRELLA LIAB X | occur Y EXC6017189-05 10/9/2016 10/9/2017 EACH OCCURRENCE $9,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000
DED | | RETENTION $ $
D | WORKERS COMPENSATION 6JUB-2E48371-0-14 (AZ) (AZ 10/9/2016 10/9/2017 WE STATU- Orn
TORY LIMITS ER
AND EMPLOYERS’ LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE] $500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES {Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Additional Insured extension of coverage is provided by above referenced General Liability policy where required by written agreement.
Date of Display: October 14, 2016
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. 5ist Avenue AGCORDANCE WITH THE POLICY PROVISIONS.
Glendale AZ 85308
AUTHORIZED REPRESENTATIVE
PH)
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© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

HS
Creek AZ
Anthem,
Boulder
|
info@fireworksaz.com
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