LEISURE WORLD COMMUNITY_REDACTED.PDF

MARICOPA 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,
10" Floor, Phoenix, 85003 (602-506-3766) at least 30 days prior to the event date.

All applications must have the following documentation attached:
4. 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 RECEIVED

Name/Organization: — Leisure World Community

OCT OH 1025

Name of Event: Community Event
Event Address: 908 S Power Rd. Mesa AZ 85206 LA DIFADA COLINTY
Date and Time of Event: Tuesday, November 11,2025 _ at 6:45PM CLERK BOARD OF SUPERVISORS

DISPLAY DIRECTOR (permit will be issued to the followin

Name: Cody Welty nn Phone: 480-948-0090 office
Business; Fireworks Productions of Arizona Fax: “A932.
Address: 17034 S 54th St. Chandler AZ 85226 =

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.

FIREWORKS DISPLAY SITE MAP

Indicate the following:

Fire department access
Hydrants

Distance to structures
Overhead lines

North direction

Distance from firing area to impact/fallout area
Spectator location

Storage area

Pens
PAA A

(North)

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

a J DATE (MM/DDIVYYY}
ACORD CERTIFICATE OF LIABILITY INSURANCE 9/22/2026

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(ios) 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 fae
Acrisure Great Lakes Partners Insurance Services on: FAX
223 West Grand River Ave #1 AiG No. Ext): ~ AUC, No:
Howell Mi 48843 ADDRESS: ee a
a INSURER(S) AFFORDING COVERAGE _ NAIC #
. INSURER A: AXIS Surplus Insurance Company 26620
INSURED i Travelers Pi Casualty Company of America 25674
FPA, Ltd, DBA: Fireworks Productions of Arizona suena. Travelers Property Casually Company
47034 § 54th St insuRER ; Third Coast Insuran 10713
Chandler AZ 85226 INSURER D: Allianz Global Risks US Insurance Company 35300
INSURER E ae
INSURER F :
COVERAGES CERTIFICATE NUMBER: 246845086 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.

[ADDL] Ry]

INSR ], POLICY EFF | POLICY EXP
Lik TYPE OF INSURANCE ISR Lv POLICY NUMBER {MIDDIVYYY) | [AIN/DDSYYYY) LIMITS
C | GENERAL LIABILITY GL BINDER 10/972025 10/9/2026 | EACH OCCURRENCE $1,000,000
x -p DAMAGE TO RENTED
X | COMMERCIAL GENERAL LIABILITY | PREMISES (Ea occurrence) _| $890,000
CLAIMS-MADE OCCUR MED EXP (Any one person) |S.
PERSONAL & ADVINJURY _| $ 1,000,000
GENERAL AGGREGATE $2,000,009
GENL AGGREGATE UMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $2,000,000
poucy | X | SES Loc §
ABINED SINGLE LIMIT
© | AUTOMOBILE LIABILITY AUTO BINDER 10/0/2025 terzoz6 | FOMBINED § $ 4.000.000.
X | any auto BODILY INJURY (Per person) | &
ALL OWNEO SCHEDULED
thes Pray BODILY INJURY (Per eccident)! $
x X | NON-OWNED PROPERTY DAMAGE. 3
HIRED AUTOS, AUTOS (Per accident) on =
§
A UMBRELLALIAB =| X | aggur P-001-000601697-05 10/9/2025 10972026 | EACH OCCURRENCE $4,000,000
X_| EXCESS LIAB CLAINS-MADE AGGREGATE $ 4,000,000
veo | l RETENTION S$. $
B | WORKERS COMPENSATION BIUB-1W11896.8-25(A7) 4019/2025 Yorno2s (x | WOSTATU- OTH-
AND EMPLOYERS’ LIASILITY YIN aa) Tears FR
ANY PROPRIETOR/PARTNER/EXECUTIVE [ E.L, EACH ACCIDENT $1,000,000
OFFICERMEMBER EXCLUDED? NIA
{Mandatory In NH) ELL. DISEASE - FA EMPLOYEE] $ 1,000,000
If yes, describe under
SCRIPTION OF OPERATIONS below E.L_DISEASE - POLICY LIMIT | $1,900,000
D | 2nd Excess EXCESS 2 BINDER 10/812025 10/9/2026 | Fach Occurrence §,000,000
Aggregate 5,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Romarks Schedule, If more space Is required)
Additional Insured extension of coverage is provided by above referenced General Liability and Auto Liability polcies where required by written agreement.
Date of Display: November 11, 2025

Location of Display: Coyote Run Golf Course at Leisure World Community |

Additional Insured(s): State of Arizona; Maricopa County; Rural Metro Fire Department; Leisure World Community Association; Coyote Run Golf Course.

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED iN

Leisure World Community Association ACCORDANCE WITH THE POLICY PROVISIONS,

Finance Department

908 S, Power Road AUTHORIZED REPRESENTATIVE
Mesa AZ 85206

, oof Yo

© 1988-2010 ACORD CORPORATION. Ail rights reserved.

ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

2Class ZA Pressunzed
Water Fire Extinguishers

; 7 - 693 Leisure World
Maximum Shell Size: 1.5” Basins

Fireworks Productions of Arizona 480-948-0090 info@fireworksaz.com

EXHIBIT A

LEISURE WORLD COMMUNITY

Mesa
Tuesday, November 11, 2025
5 —6 minute display
1,200 Basin Effects

This celebration contains a combination of fiery color and sparkling fireworks to thrill and
electrify the competitors, attendees and their guests.

5 - 6 Minute Aerial Basin Display:

Your Aerial Basin Display will contain a total of 1,200 aerial basin effects
(including numerous Basins using Red, White and Blue effects)

1.5” - 12 FPA Premier Multi-shot Specialty Basins
(5 - 10 seconds between basins; pause before the GF)

(9 Multi-shot Basins fired one after another or together followed by 3 Multi-shot Basins fired

simultaneously for the Grand Finale)

Leisure World would like Patriotic colors whenever possible, especially for the

Grand Finale

Designed for the [ eisure World Community by: Fireworks Productions of Arizona

3

City of Phoenix
FIRE DEPARTMENT

FIRE PREVENTION SECTION

Pyrotechnician
Certificate of Fitness

Cody Welty

R2300047

Expiration Date: 05/04/2026

The above individual has been issued a
Pyrotechnician Certificate of Fitness
in accordance with the Phoenix Fire Code §105.11.
This Certificate of Fitness is not transferable and expires on the
date listed above. This Certificate of Fitness does not represent
endorsement or employment by the Phoenix Fire Department or
the City of Phoenix.

ey

John Mertens
City of Phoenix Fire Marshal

October 7, 2025

Clerk of the Board of Supervisors
Maricopa County

301 W. Jefferson 10" Floor
Phoenix, AZ. 85003

To Whom It May Concern:

Attached is the permit application for Leisure World Community event
fireworks display scheduled for Monday, November 11, 2025. Rural Metro
Fire District will be the responding fire department and I’ve emailed them to
confirm that they are aware of and have no objections to the display.

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: Cindy Herbel

17034 8. 54" Street
Chandler, AZ. 85226

If you have any questions or need any additional information, please do not
hesitate to contact my office. Thank you very much!

Pyrotechnically Yours,

Cindy Herbel
Pyro Office Assistant

Callie Hunt (COB)

ll aameamaneaiail ace el
From: Kenneth Diamond

Sent: Wednesday, October 8, 2025 1:26 PM

To: Cindy Herbel

Subject: Re: Fireworks - Nov 11 - Leisure World

| am aware of your shoot at Leisure World and have no objections. Approved

Kenneth Diamond
Fire Marshal
Fire Plans Examiner

Central Arizona Fire Operations
(480) 869-2340

SS RURAL

www.ruralmetrofire.com

From: Cindy Herbel
Sent: Tuesday, October 7, 2025 11:24 AM

To: Kenneth Diamond [a

Subject: [EXTERNAL] Fireworks - Nov 11 - Leisure World

*** WARNING: Email originated from outside the organization. Do not click links or open attachments
unless sender is verified. ***
Hello again,
Attached is the following for a fireworks display for Leisure World - Veteran’s Day display on Tuesday,
November 11, 2025: ,
* Notification letter
e Show Program
e Site Map
« Col

Please let me know if you have any questions or need anything else. If you have no objection, please let
me know and | will include that response with our Maricopa County application.

Cindy Herbel

Pyro Administrative .
Assistant

/ “Fireworks :
Productions |
of Arizona
480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)

17034 S. 54th Street, Chandler, AZ 85226

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