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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 INFORMATIONName/Organization: Anthem
Name of Event:July 3rd, 2022 Fireworks Display
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086
Date and Time of Event:July 3rd, 2022@ 9:00 PM
DISPLAY DIRECTOR (permit will be issued to the following)
Name:Randy Reyman =
Business:Reyman Pyrotechniques/Any Pyro Fax:
SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO:
Maricopa County Clerk of the Board of Supervisors Email: ClerkBoard@maricopa.gov
301 W. Jefferson Street, 10" Floor Fax: 602-506-6402
Phoenix, AZ 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
1. North direction
2. Distance from firing area to impact/fallout area
3, Spectator location
4. Storage area
ONO”
(North)
FOR DEPARTMENT 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
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 on:
DATED this day of 20
Clerk of the Board, Authorized Signature
DATE (MMIDDIYYYY}
—~* 4
ACORD CERTIFICATE OF LIABILITY INSURANCE 54/2022
THIS CERTIFICATE 1S 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 polley, 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 Rae’ Keisly Wolfe
Ryder Rosacker McCue & Huston (MGD by Hull & Compa ian sha “| FAX
509 W Koenig St ii AIG. Nal
Grand Island NE 68862 oo .
ee INSURER{S) AFFORDING COVERAGE RAIGH
ee _ insurer A: SCOTTSDALE IND CO - |. 45580
INSURED 7
eater Any Pyro INSURER B : ee
INSURER: | 7
INSURERD: —
INSURER _ a
INSURER Fs
COVERAGES CERTIFICATE NUMBER: 1571295857 REVISION NUMBER:
THIS {S 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 OOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 8Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUGH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR’ ADDL|SUBR a POLICY EFF | POLICY Exp -
LTR _ TYPE OF INSURANCE INSRIVEVD. POLICY NUMBER (MAIDONY YY) | (MAVODAYYYY) LMITS
A | GENERAL LIABILITY CPICQEASEa 492021 62022 | EAGH OCCURRENCE ” $ +,c00,ca0
ones pect hk _— _
X | COMMERCIAL GENERAL LIABILITY i | PREMISES (es oesurenco) _| $400,000
| J etains-ntane |X | | occur MED EXP IAny cae pecan) [$5,000 a
ee PERSONAL & ADV INJURY _| $ 1,009,009
_ - _GENERAL AGG! | $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: i _PRODLCTS 3 | $2,000,000 _
X]poucy{ FRE | | toc : _ §
AUTOMOBILE LIABILITY COMBINED SINGLE un
___| any aura BODILY INJURY (Per porsan} | $ _
(ALL gWNeD | SCHEDULED | BODILY INJURY (Per acciden!}, $
—_ j NON-OWNED: PROPERTY DARAGE
HiREOAUTOS «|__| auTOS {Pot accident) i —
i | $
T
__| UMBRELLALIAB = occur LEACHOCCURRENCE = [$0
|__| EXCESS UAB | _: GLAIMS-AADE| _AGGREGATE _|s
eo | | RETENTION $ §
WORKERS COMPENSATION Tic Siaju- | OTH
| ANO EMPLOYERS" LIABILITY yen po TORY LIMITS i___ER
ANY PROPRIETORPARTNERIEXECUTIVE H ELL. EACH ACCIDENT $
OFFIGERMEMDER EXCLUDED? NIA DENT
{Mandatory in NH} ~ E.L, GISEASE - EA EMPLOYEE) $
It yes, Cagcrbe under ~~ i .
DESCRIPTION OF OPERATIONS tolow 1 E.L DISEASE - POLICY UIMIT | $
j
DESCRIPTION OF OPERATIONS / LOCATIONS J VEHICLES (Attach ACORD 104, Additional Remarks Schudula, if mare space ls required)
Regarding the Generai Liability coverage, Blanket Additional Insured applies to the entities listed below per attached form GLS-150s when required by written
agreement.
Regarding the General Liabillly coverage, Waiver of Subrogation applies to the entities listed below per attached form CG 24 04 when required by written
agreement.
Blanket Primary & Non-Contributory shawn below is added per weilten agreement and form CG2001 attached ta this palicy
Additional insureds: Anthem Community Couneil Inc. Anthem Parkside Community Association Inc.; Anthem Country Club Community Association Inc,;
Maricopa County, State of Arizona, Daisy Mountain Fire District; AAMLLC, their respective and affiliated entities and all of their respective directors, officers,
pariners, members, empioyoes, and agants are hereby named as additional insured. insurance is primary and noncontributory. Display date is 07/03/2022
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem Community Council
3701 W Anthem Way Ste #201 FUTHORIZED REPRESENTATIVE
Anthem AZ 85086 Qu he
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
eae
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMDDIYYYY}
06/02/2021
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 have ADDITIONAL INSURED provisions or be endorsed.
lf 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 leu of such endorsement(s).
PRODUCER: CONTACT :
Ryder, Rosacker, McCue & Hustan bata? tn
509 W, Koenig St. ROUMESS: — |
Grand Island NE 68807 _____ INSURER(S) AFFORDING COVERAGE NAIA
pave INSURER A; Travelers Assigned Risk _
INSURED INSURER 8 = —|
Randy Reyman dba INSURER CG;
Reyman Pyrolechniques!Any Pyro INSURER D; =
INSURER E. sip hacen
| INSURER F +
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;
THIS 1S 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 GONTRACT 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,
_EXGLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
sR
TYPE OF INSURANCE
ADDL, ‘SuBRT
Wiuso vivo |
_ | CLAIMS. MADE |
COMMERCIAL GENERAL LIABILITY
| OSCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY NUMBET —{MIMIDDLY YY) + “iil IDDYY YY).
| POLICY EFF | POLICY Exp. ca
EACH OCCURRENCE 7
DAMAGE TO RENTED
| PREMISES (Ea oni F
MEO EXP (Any cap vation Me
PERSONAL & ADV INJURY
GENERAL AGGREGATE
| Pouicy TBS: } Loc FRODUGTS - COMPIOP AGG
OFYEER:
AUTOMOBILE LIABILITY
[__] anv auto BODILY INJURY (Per gerson) |
|| Aas ONY LI SCHEDULED BODILY INJURY (Par accident) S
RED NON-OWNED PROPERTY GAMAGE
__| AuvOs ony ANTOS ONLY | (Par accident) =
UMBRELLA LIAB occur
EACH OCCURRENCE
3.
3
Ss
3.
Ss
S
CONGINED SINGLE = ry
§
s
$
3
3
$
s
AND EMPLOYERS’ LIABILITY
(Mandatory in NH
Wyee, ceacrbe under
ANY PROPRIETOR/PARTNERIEXECUTIVE
A OFFIGERUMEMBER EXCLLOED?
CRP TION OF OPERATIONS belery
EXCESS LIAB CLAIMS-MADE AGGREGATE
oco |_| perewniows
WORKERS COMPENSATION x [Re | [er
vin
bolle 6JUB-5R86638-5-21
cHaccw@enT | s 100,000
EL. DISEASE - FA EMPLOYEE! $ 100,000
OWO12021 OiNi/2022
E.L DISEASE - PoLicy Livan | $ 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS } VEHICLES (ACORD 101, Additional Remarks Schudule, may bo attachad if mora space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIGED POLICIES BE CANCELLED BEFORE
Anthem Community Council THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN
3701 W Anthem Way Ste #201 ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem, AZ 85086
AUTHORIZED REPRESENTATIVE al <WiM>
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
dew ung
ALIs HON
am community park - Bing https:www.bing.com/maps?q=anthem+community+park&pe=,.,
Py trininee
Notes
orfenasnss
Reyman Pyrotechniques/Any Pyro
Anthem 7/3/2022
Content of display
Following is the shell content of the display:
2 1/2 inch shells-42
3 inch shells-144
4 inch shells-72
5 inch shells-72
jy datemnational dsspaalion
Wa #
yok ings Soeooigiaus
MenBER
RANDY L.
REYMAN
REYMAN PYROTECHNICQUES il | ill Il | HH | ie
ey PAAR RS
City of Flagstaff Fira Department
211 W. Aspen Avenue
Flagstaff, AZ, 86004
Pyrotechnics Pormit
Parmit &
Issued By: beleél —.. Fite Inssector
Dato Issued: LE
Daisy Mountain Fire Prevention
41018 N Daisy Mountain Drive Anthem Az, 85086 623-465-7400 May 2, 2022
Mr. Reyman,
Thank you for the notice from Reyman Pyro-Techniques/Any Pyro stating you will be
conducting the fireworks display for the Anthem’s July 3rd, 2022 event and that you
are aware you will need to obtain a DMFD permit for this event. A valid County permit
shall be obtained and DMFD standby will be required on the day of the event. We look
forward to working with you again. Please let us know if you need any further
information.
Sincerely,
Dave Vichen
Dave Nielsen — Deputy Chief
Fire Prevention 623-465-7400