BOULDER CREEK HIGH SCHOOL FIREWORKS DISPLAY.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:
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: Boulder Creek High School

Name of Event: Football Game Fireworks Homecoming

Event Address: 40404 N Gavilan Peak Parkway, Anthem AZ 85086

Date and Time of Event: October 14(homecoming) @ approx. 6:45p-9:30pm

DISPLAY DIRECTOR (permit will be issued to the following)

Name: Kendon Victor (please email or mail approval back to Cindy) | phone: 480-948-0090
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address: 17034 S 54th Street, Chandler AZ 85226 Email: cindy@fireworksaz.com

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.

RECEIVED
SEP - 6 2022
MARI

CLERK BOAs

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

DATE (MMIDDIYYYY)

@
ACORD CERTIFICATE OF LIABILITY INSURANCE ea

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 CORMACT Janet Nau

The Partners Group Ltd PHONE. ext, (877) 455-5640 TAS, Noy: (425) 455-6727

11225 SE 6th St. EMAL .s, Jnauetpgrp.com

Suite 110 INSURER(S) AFFORDING COVERAGE NAIC #

Bellevue WA 98004 INSURERA: Everest Indemnity Insurance Co 10851

INSURED INSURERB: Everest Denali Insurance Company 16044

FPA, LTD, DBA: Fireworks Productions of Arizona INSURERC:AXIS Surplus Lines Insurance Company 26620

17034 S. 54th Street INSURERD: Travelers Property Casualty Co of Ameri| 25674.
INSURER E :

Chandler AZ 85226 INSURER F :

COVERAGES CERTIFICATE NUMBER: 22-23 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 POLICY EFF | POLICY EXP
LTR TYPE OF INSURANCE isp |wvp. POLICY NUMBER (MMIDDIYYYY)_| (MIVDDIVYYY) LIMITS:
X | COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
A | CLAIMS-MADE [x] OCCUR PREMISES (Ea occurrence) _| $ 500,000
x S18MLO2344221 10/9/2022 | 10/9/2023 | MED EXP (Any one person) _| $ N/A
PERSONAL _& ADV INJURY __| $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY tes LC] Loc PRODUCTS - COMP/OPAGG_| $ 2,000,000
OTHER: §
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000
B |X] anvauto S18CA00258221 BODILY INJURY (Per person) | $
ALL Owned [| Scriggue> Hired Auto Physical Damage 10/9/2022 | 10/9/2023 | BODILY INJURY (Per accident) | $
NON-OWNED ‘ PROPERTY DAMAGE
X | HIRED AUTOS AUTOS Comprehensive Ded $100 (Per accident) §
Collision Ded $1,000 $
UMBRELLA LIAB X | occur EACH OCCURRENCE s 4,000,000
c Lx_| Excess LIAB CLAIMS-MADE. AGGREGATE Ss 4,000,000
DED RETENTION $ P00100069169702 10/9/2022 | 10/9/2023 $
WORKERS COMPENSATION x | PER OTH:
‘AND EMPLOYERS' LIABILITY YIN siture | [ee
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? CL] NIA
D_ | (Mandatory in NH) 6JUB-6R0B411~5-22 10/9/2022 10/9/2023 | EL. DISEASE - EAEMPLOYEE | $ 1,000,000
Ifyes, describe under
DESGRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT_| $ 1,000,000
A |General Liab. & Auto Liab. SI8EX01790221 10/9/2022 | 10/9/2023 | Each Occurrence $5,000,000
Over $4M Excess - Per Occ. Aggregate $5,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The following are included as Additional Insured on General Liability as their interest may appear as
respects operations performed by or on behalf of the Named Insured, as required by written ontract:State
of Arizona; Maricopa County; Daisy Mountain Fire District; Deer Valley Unified School District #97;
Boulder Creek High School; Boulder Creek Football Foundation.

Date of Display: October 14, 2022

Location of Display: Boulder Creek High School, Anthem, AZ

CERTIFICATE HOLDER CANCELLATION

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

ifi Distri 7
Deer Valley Unified School District #9 ACCORDANCE WITH THE POLICY PROVISIONS.

18424 N. 51st Avenue

Glendale, AZ 85308
AUTHORIZED REPRESENTATIVE

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Jordan Stair/CCRUDE oe —

© 1988-2014 ACORD CORPORATION. All rights reserved.

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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

Pes
PNG

(North)

email to Clerk of the Board

EXHIBIT A

BOULDER CREEK HIGH SCHOOL
Anthem

Friday, October 14, 2022

HOMECOMING
Total Aerial Effects 58

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 58 aerial shells shot during important moments of
the evening to excite the home crowd and celebrate the Jaguars’ accomplishments.

2.5” - 58 Chinese Fancy’s & Specials
Boulder Creek High School’s show to consist of:

TEAM INTRO: 7 —2.5” Aerial Shells
NATIONAL ANTHEM: 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): 7 - 2.5” Aerial Shells
END OF GAME: 7 - 2.5” Aerial Shells

(Any remaining Score Shells shot at end of game)

Designed for Boulder Creck high School by: Fireworks P: ‘roductions of Arizona

Daisy Mountain Fire Preventjon

41018 N Daisy Mountain Drive Anthem Az. 85086 623-465-7400 August P3, 2022

Ms. Cindy Herbel,

Thank you for the submittal from Fireworks Production of Arizona requesting to conduct

the fireworks display for the Boulder Creek Homecoming event on October 14° 2022 and

obtaining a DMFD permit for this event. Your site plan, operator, andidisplay plan are
approved. A valid Maricopa County permit will also need to be obtained

Due to the high wildfire danger this season, please be advised if therd is any extreme

wildfire conditions, extreme weather conditions, or if there is an attive large- scale

emergency event the day of the event, DMFD may have to cancel the fiteworks display.

We look forward to working with you again. Please let us know if you heed any further

i
informati on, |

Sincerely,
Dave Wichenr

Dave Nielsen — Assistant Chief
Fire Prevention 623-465- 7400

seein is

DAISYMOUNTAIN
41018 N DAISY MOUNTAIN DR

ANTHEM, AZ 85086

Permit Certificate DMFD
Date: 08/23/2022
Business Name; FIREWORKS PRODUCTION OF ARIZONA {
Address: 17034 54TH sT
CHANDLER, AZ 85226 {
Phone; MAIN 480-948-0090
The following permit has been issued: i
Permit No. 2223-026 Type: FIREWRKS FIREWORKS SALES/DIS PLAY
Issued Date: 08/23/2022 OCCUPANT LOAD: a
Effective Date: 10/14/2022 ;
Expiration Date: 10/14/2022
{
Notes:
i
Applicant Information Fireworks Productions, of Aridbna
Address 17034 S 54th st |
Chandler Arizona 85226 |
Contact Person Ms Cindy Herbel i
(Email cindy@fireworksaz.com |
Phone — 480-948-0090 :
Fax 480-423-5430 i
Notes or Description of the construction or coe rati one Outdoor
fireworks display for Boulder Creek High School footb411 games on
October 14 and November 10 for homecoming and'senior jight. Display
will be intermittently during the games. i
It is the business's responsibility to ensure that conditions| are in
accordance with applicable State and Local fire regulations.
Obtain any permits that are required by the State of Arizona and the County
having jurisdiction. 08/23/2022
Inspector: DMFD FIRE PREVENTION Date |
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