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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. NAMEIORGANIZATION St. Rose Philippine Duchesne Catholic Parish EVENT ADDRESS 2825 W. Rose Canyon Circle, Anthem AZ 85086 DATE AND TIME OF EVENT October 15, 2016 @ approx. 9:00pm - 9:30pm 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. 541h Street, Chandler AZ 85226 Email: SignatkrINII Display•V*ctor Date 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 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 347250 KNOW ALL PERSONS BY THESE PRESENTS, that we FIREWORKS PRODUCTIONS OF AZ LTD. 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 SALT RIVERPIMA bound unto MARICOPAINDIANCOMMUNITY State of Arizona in the sum of TwoThousandDollars DOLLARS (02,000.00 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. WHEREAS the above bounden Principal FIREWORKSPRODUCnONSOFAZLID. desires to have a permit for Fireworks Display and in order to have such display it is necessary for said FIREWORKS PRODUCTIONS OF AZ LTD. to execute a surety bond in the amount of TwoThousandDollars Dollars ($ $2,000.00 ) 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. NOW, THEREFORE, if the said FIREWORKS PRODUCTIONS OF AZ LTD. 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. IVIay 25, 2016 to 12:01 A.M. May 25, 2017 then this obligation to be void, and of no effect. SIGNED, sealed and dated this 1st day of March 2016 FIREWORKS PRODUCTIONS OFAZ LTD. Principal MERCHANT5.130NDPIVON,V (MUTUAL) By Attorney-in-fact Eli Krambeer LP 0265 AZ (2/15) Daisy Mountain Fire Prevention Mrs. Harris, Thank you for the notification that Fireworks Productions of Arizona will be conducting the firework display for the St. Rose Philippine Duchesne Parish event in Anthem on October 15th, 2016. As in the past, once you have the required County permits, you can apply to the Daisy Mountain Fire District for a site permit, inspection and stand-by units. This site has been approved in the previous years and we look forward to working with you again. Please let us know if you need any further information or if there will be a major change to the site from last year. Respectfully, D.Akt€4244 Dave Nielsen Fire Prevention Division Chief Fire.Marshal@dmfd.org Phoenix Certificate of Fitness August (Fielding) Heckendorf Head Pyrotechnician Certificate of Fitness for Pyrotechnics tr. l'110,111 ,. I Ir. I krarittl,:l: AUGUST HECKENDORF )utdoor - Frnplod hy . R E C n Card ExPttes - 5i I 4 , 2 C. Nal- A FIRE DEFT VAIN ()YEE Certificate of fitness is not transferable and may be reioked anct 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 actrot es cerfcrmed by the cardholder 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 15, 2016 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 FPA 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 Desneci for 5t. Kose fAilippine Duchesne Catholic farish by: Fireworks froductions of Arizona ,----N, 0 Acc•RE. DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 4.----- 8/19/2016 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 NAME: Britton Gallagher PHONE FAX One Cleveland Center, Floor 30 1A/C. E-MAIL No. Exo.216-658-7100 (A/C, No): 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 26743 FPA, Ltd. INSURER c :Everest Indemnity Insurance Co. 10851 17034 S 54th S t INSURER D Travelers Property Casualty Co. of Chandle r AZ 85226 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1252250751 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 VVVD POLICY NUMBER (MM/DDIVYYY) POLICY EFF (MM/DD/YYYY) POLICY EXP LIMITS C GENERAL LIABILITY Y SI8ML00014-151 10/9/2015 101912016 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) $ PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000 ,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 —I POLICY X 171E-1'. LOC $ AUTOMOBILE LIABILITY Y SI8CA00008-151 10/9/2015 1019/2016 COMBINED (Ea accident) SINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY (Per person) $ AUTOS ALL OWNED AUTOS SCHEDULED BODILY INJURY (Per accident) $ X HIRED AUTOS AUTOS NON-OWNED PROPERTY (Per accident) DAMAGE $ $ UMBRELLA LIAB _ X OCCUR Y EXC6017189-04 1019/2015 10/912016 EACH OCCURRENCE $9,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000 DED RETENT ON $ WORKERS COMPENSATION 6JUB-2E48371-0-14 (AZ) 10/9/2015 1019/2016 X TORY WC STATU- LIMITS 0TH- ER AND EMPLOYERS' LIABILITY YIN ANY OFFICER/MEMBER PROPRIETOR/PARTNER/EXECUTIVE EXCLUDED? N /A EL. EACH ACCIDENT $500,000 (Mandatory in NH) EL. DISEASE - EA EMPLOYEE $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. 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 15, 2016 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 --)/ I © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD rireworks Site Map Display rroductions Site of Arizona Maximum Shell Size: 480-948-0090 2.5" Aerial info@fireworksaz.com St. Anthem Rose Parish