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(2 indivikdo CLERK MARICOPA COUNTY BOARD OF SUPERVISORS weer ifort cone ‘$301 West Jefferson Street, 10th Floor, Phoenix, Arizona 85003 2015 APR 17 AM 9: 36 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, 10" 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: A Nl + é mw Namie GtEVOnE A KI t he Mm Community Su Qi Va Ia, 2015 Fyeoens D Sf leu Event Address: (1 (74 03 Al. (s AN ™ Peak Wrork wo Az, RSOPG, wy Anvthun Date and Time of Event: aT 7 vg 2015 @ Fi00 hm : , DISPLAY DIRECTOR (permit will be issued to the following) Name: Ra MD tin On Phone:/,02- YY¥& - /033 4 Business! FE PYM teh rithues/ Auy fypo_|Fax:20b 239-1299 mans - Aceves: ee |E=: C py ro Osa. com iy SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO: Maricopa County Clerk of the Board of Supervisors Email: ClerkBoard@mail.maricopa.gov 301 W. Jefferson Street, 10" Floor Fax: 602-506-6402 Phoenix, Arizona 85003 For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766. 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 Cierk of the Board, authorized signature CERTIFICATE OF INSURANCE ISSUE DATE 2/18/2015 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LATER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PROFESSIONAL PROGRAM INSURANCE BROKERAGE 371 BEL MARIN KEYS BLVD., SUITE 220 INSURER(S) AFFORDING COVERAGE NOVATO CA, 94949-5662 INSURER A: LLOYD'S OF LONDON INSURED INSURER B: Randy Reyman DBA: Any Pyro & Reyman Pyrotechniques INSURER C: 2937 N. 29th Street 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 POLICY EFFECTIVE | POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDDIYY) LIMITS air LIABILITY EACH ACCIDENT $1,000,000 LAMB: MADE MEDICAL EXP (Any one A Berson) $ PY/14-0162 11/22/2014 41/22/2015 | FIRE LEGAL LIABILITY $ 50,000! GEN’L AGGREGATE LIMIT ‘ . GENERAL AGGREGATE $__ 2,000,000 Pursuant to Arizona Revised Statutes section 20-401.01, APPLIES PER POLICY s i : thi icy is i by an PRODUCTS-COMP/OPS AGG | $ AUTOMOBILE LIABILITY insurer that does not possess a certificate bf authoriy ae acusied LIMIT i - $ from the director the of = anyauto of eieona Departin ut BODILY INJURY ANYOWNED AUTOS Insurance, If the insurer that issued this policy becomes (Per person) $ — UTOS Soe ins Ivent, insureds or claimants will not bp eligible for een | $ NON-OWNED AUTOS — insurance guaranty fund|protection pursuant to Arizona PROPERTY DAMAGE $ EXCESS LIABILITY FOLLOWING FORM EACH ACCIDENT $ AGGREGATE $ WORKERS COMPENSATION ee mink ag $ AND E.L.EACH ACCIDENT $ EMPLOYERS?’ LIABILITY E.L, DISEASE-EAEMPLOYEE | $ E.L_DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Anthem Community Council, Inc.; Anthem Parkside Community Association, Inc.; Anthem Country Club Community Association, Inc.; State of Arizona and Maricopa County are additional insureds as respects the 7/2/2015 aerial fireworks display located at Anthem Community Park. This insurance is primary and non-contributory to any other insurance available to the additional insureds. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL Anthem Community Council, Inc. DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT 3701 W. Anthem Way, Suite #102 FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS apse Anthem, AZ 85086 conti sdied? AUTHORIZEVREPRESENTATIVE Anthem Community Park Fire Juggler Water Slides. inflatables S| E ee SUM SG ee ia p4 AO 80 pe pedo ~’ \) EB & no o. 2. anthem shells Reyman Pyrotechniques/Any Pyro Anthem Display, 7/2/15 Content of display Following is the shell content of the display: 2 1/2 inch shells-70 3 inch shells-216 4 inch shells-210 5 inch shells-150 Page 1 a eine Intemational Association @ , = 4 = Oz a af Bomb Technicians ee & favestiqatoss MEMBER ID: 369241 RANDY L. REYMAN REYMAN PYROTECHNICQUES mK P Member Class: ASSOCIATE” Region: J a sceieem treet te City of Flagstaff Fire Department : 211 W. Aspen Avenue P Flagstaff, AZ, 86001 Ce Tcl Pyrotechnics Permit Applicant: Randy Reyman Permit Holder; Randy Reyman Dit Permit # 9AZ013210H03233 DOB: SS#: D Ma. issued By: _/ 2202 7( Fito Inspector (a ; (fe LH Date Issued: THIS CERTIFICATE IS NOT TRANSFERABLE AND MAY BE REVOKED FOR-CAUSE NOT TO BE USED OUTSIDE CITY OF PHOENIX 2S:5000 Mew S97 CATY OF PHCIRK, ARIES UA ln DERABTUAEN? = dag OF ARE pet Mr. Reyman, Thank you for the notification that Reyman Pyrotechniques/Any Pyro will be conducting the firework display for the Anthem’s July 2015 Event. As in the past, once you have the required County permits, you can apply to Daisy Mountain Fire District for a site permit, inspection and stand-by units. This site has been approved in 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. Dave Nielsen Fire Prevention Division Chief Fire. Marshal@dmfd.org 623-465-7400