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 Before
any person. 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 goveming 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 | St. Rose Philippine Duchesne Catholic Parish
EVENT ADDRESS | 2825 W. Rose Canyon Circle, Anthem AZ 85086
DATE AND TIME OF EVENT | October 18, 2013 @ approx. 9:00pm
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. 54" Street, Chandler AZ 85226 Email:
sarah@fireworksaz.com
CN
AN A/os 1%
Director Date ~
Stanafiep OnDsplty
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 fireworks
a
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
2100 FLEUR DRIVE » DES MOINES, IOWA 50321-1158
{515} 243-8171 + (515) 243-3854 FAX
FIREWORKS DISPLAY BOND
KNOWN AGL PERSONS ry THESE FRESEXTS, that we
FPA, Lid. dba Fireworks Productions of Anzona
as Frincipai, asd MERCHANTS ZOSDING COMTANY (MUTUAL), a corporstiou
orgenized tinder the laws cf the State er Iswa, with it3 nome cffice in the
City of Des Jicines, Towa, and duly authorized and licensed t. do business in
the State of Arizona, as Surety, are firmly bevid unto Maricopa County
Skate of Arleona
in the sum oF Oue Thousand Dollars
DOULBARS (£51,000.00
saviul money cof tne United States, to the nayment of which well and
sum,
troiiy te be made, the Principal ens Surety bind thesselves, trteir end each
of their heirs, executors. administret Ong, successors and
assigns, jointly
anc severally, firnly by thasse presertea.
FPA, Ltd. dba Fireworks Procacions
WHEFEAS the acove bounsean Feincipal of Arizona
cesizes to have a permit for Fireworks Display ana in corde: to» have such
aisplay it ie necsesary for saic FPA.Ltd dba Fireworks Productions of
Anzona
to execute a sisety bond 12 the amount of One Thousand Dollars
Dzliars (S$ §&1,000.00 }) conditioned for che saymeat cf all Willen
dane yes may
be causea te persons or Eroperty >y reascn of tre permitted display as
proviued in Cnapter 4€, Az:izona Leyislavive Session Taws cf 1941,
FPA, Ltd. dbx Fireworks Productions of
NOW, THEREFORE, if tha said Arizona
ya ena truly observe, cerry out, perform and comply with all reqvireairerts,
erms and prowisions cf the Ordinanzes of the Buord cf Supervisors cf
Maricopa
State cf Arizona,
Gonditionec Tox the payment of all demeges waich ray Pai te caused to
persons or
property oy reascn of the permitted discliay as provided in Thapter 46,
Arlzoné Legisletive Session Taws of 1941, for a period from 12:67 Alef.
August 23, 2013 to 12:02 AB August 23, 2014
then this
ebligation to he void, and of so effect,
SIGNED, sealed and deted this 27th gay af August 2013
,
SP, Lud. dba Fireworks Productions of
Arizona
Principal
ERASE
2
LAK cefuey-in-fact Lisa M Hankal
LP 0265 Az (12/995

Mr. Victor,
Thank you for the notification that Fire Works Production of Arizona will be
conducting the October 2013 firework display for the St. Rose Perish Event in
Anthem. We have met with you, the Church, and approve of your preliminary site
plan. Once you have the required County permits, you can continue with the
application process that Daisy Mountain Fire District requires for a site permit,
inspection and stand-by units. Please be aware that this year our Fire Prevention
staff has been reduced and we are requiring advanced notice to ensure that we
can get the permit request processed in a timely manner. Please let us know if
you need any further information.
Respectfully,
Dave Nielsen
Division Chief - Fire Prevention
Fire.Marshal@dmfd.org

Fireworks’*/\*5
Productions |
of Arizona
Phoenix Certificate of Fitness
Kendon Victor
Head Pyrotechnician
602-672-9313
Fireworks Productions of Arizona
1-877-948-0090...info@fireworksaz.com

EXHIBIT A
St. Rose Philippine Duchesne Catholic Parish
Friday, October 18, 2013
10 minute display
Total Aerial Effects 650
Total Shelis 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%” - 4FPA 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
Designed for St Kose fF hilippine Duchesne Catholic Parish
by: Fireworks Productions of Arizona

—™
eS
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D| a“
9/9/2013
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 confer
not rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
Britton Gallagher PHONE
One Cleveland Center, Floor 30 Hale No. Ext: 16-658 2100 LB, FAX nox216-658-7401 |
1375 East 9th Street ADDRESS:
Cleveland OH 44114
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A ‘Iilinois National Insurance Co 3817
INSURED
INSURER B :‘Miaxum Indemnity Company 6743
eee goad of Arizona Ltd. INSURER ¢ ‘Travelers
606
17034 th St
Chandler AZ 85226 INSURER 4d :Lexington ayi In Co
D
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1979048959 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
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES TO WHICH THIS
DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
CLAIMS.
ri TYPE OF INSURANCE ADDL|SUBR MAUDOWYYY) P icy
INSR| WD POLICY NUMBER | iMMWDONT TY) LIMITS
D er GENERAL LIABILITY Y 43924775-05 10/9/2013 10/9/2014
EACH OCCURRENCE $1,000,000
IX | COMMERCIAL GENERAL LIABILITY MAI RENTED
PREMISES (Ea occurrence) _| $50,000
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 esl [| L060
$
A | AUTOMOBILE LIABILITY Y
CA626588611 nove2o13 flofe/2o14 | COMBINEDSINGLE TMT
To oa
X | ANY AUTO
BODILY INJURY {Per person) | $
ALL OWNED SCHEDULED
X_| HIRED AUTOS AUTOS
(Per accident) $
$
B UMBRELLA LIAB X | occur Y EXC6017189-03 HO/9/2013 10/9/2014
EACH OCCURRENCE $9,000,000
XxX _| EXCESS LIAB CLAIMS-MADE
AGGREGATE $9,000,000
pep |__| ReTENTIONS
$
(© | WORKERS COMPENSATION 4864P073
AND EMPLOYERS’ LIABILITY Norii2013 nar2o14 |x| WE STATO. |x [OTH
YIN ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? NIA E.L. EACH ACCIDENT $500,000
(Mandatory in NH)
If yes, describe under E.L. DISEASE - EA EMPLOYEE, $500,000
DESGRIPTION 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)
Date of Display: October 18, 2013
Location of Display: St. Rose Parish
Additional Insured{s): State of Arizona; Maricopa County; Daisy Mountain oo Fire District; St. Rose Philippine . Duchesne.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
St. Rose Philippine Duchesne ACCORDANCE WITH THE POLICY PROVISIONS.
2825 W. Rose Canyon Circle
Anthem AZ 85086
AUTHORIZED REPRESENTATIVE
Gaubrdsipe>
© 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.com
Locations
Hydrant
Fire
& Pressurized Extinguishers Aerial
2-A 2.5” 480-948-0090
Fire
Class Water Size:
s 2
Shell
Maximum
Arizona
of
=
ae Site Productions
i) Display Map
Fireworks
Site

Pireworks Productions of Arizona
RECEIVED
SEP t 1 2013.
September 9, 2013 MARI
CLERK BOARD OF SUPERVISORS
Clerk of the Board of Supervisors
Maricopa County Board of Supervisors
301 W. Jefferson
Phoenix, AZ. 85003
To Whom It May Concern:
Attached is the permit application for St. Rose Philippine Duchesne Catholic
Parish Fireworks. 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