Extracted text (via ocr_local)
12154 characters
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:Skate Park Opening
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086
Date and Time of Event:March 12th, 2022 @ 6:45 PM
DISPLAY DIRECTOR (permit will be issued to the following)
Name:Randy Reyman =< ll
Business: i 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:
North direction
Distance from firing area to impact/fallout area
Spectator location
Storage area
Fire department access
Hydrants
Distance to structures
Overhead lines
RECEIVED wi
FEB 1 4 2999
PeENs
ON Oa
MARICO! IJUNTY
CLERK BOARD Ci SUPERVISORS
(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
a Fat a Ps ap a tt ns On ng Pa a tn Pa
a aa a
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 on:
DATED this, day of 20
Clerk of the Board, Authorized Signature
DATE {MIAIDDIY¥YY)
Paap
ACORE CERTIFICATE OF LIABILITY INSURANCE 271412022
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: [f the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policles may require an endorsement. A statement on this certificate does not confor rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER SHC" Kristy Woife
Ryder Rosacker McCue & Huston (MGD by Hull & Compa PHONE
609 W Koenig St HE AATL =|
Grand Island NE 68802 ADDRESS, a
= INSURER(S) AFFORDING GOVERAGE NAIC #
a — ee Insurer A; SCOTTSDALE IND CO ___ 18580
INSURI . INSURER B: . = —
ues / Any Pyro igautian - :
INSURER
INSURER
INSURER F i
COVERAGES CERTIFICATE NUMBER: 503238756 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 DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
sR) ADDLISUBR OLICYEFF | POLICY Exe 7
IER ‘TYPE OF INSURANCE INS] WD. POLICY NUMBER. (ARIDDIVYYY) | (ARIODNY TYE LiMers
A | GENERAL LIABILITY CrinOE46a6 eiaizoz1 8192022 | EAGH OCCURRENCE $1,000,000
X | COMMERCIAL GENERAL LIABILITY } PREMISES (Ea ee sh |$100000
| cramsamaoe |X | occur MEDEXP (Any cne porsan) _| $5,000 _
|_| : = PERSONAL & ADV INJURY _ | $ 4,000,000
| GENERAL AGGREGATE $2,000.00)
GEN\, AGGREGATE LIMIT APPLIES PER: | _PRODUGTS - COMPIOP AGG | $2,009,000 |
PRO-
X1| saucy S| | 08 CONBINED SINGLE LiniT :
5 :
| AUTOMOBILE LIABILITY yh s
ANY AUTO | BODILY INJURY (Per persan) | §
a SCMEQULED BODILY INJURY (Par aecicant)| §
NCN-OWNED PROPERTY OAMAGE —
HIRED AUTOS AUTOS ronan, = $
i $
|__| UMBRELLA AS occur EACH OCCURRENCE $ =
EXCESS LIAB ig | CAAIMS-MADE| AGGREGATE $
DEO | | RETENTIONS | 5
WORKERS COMPENSATION | WC STATU- ore
AND EMPLOYERS’ LIABILITY vs TORY LATS ER -
ANY PROPRIETORIPARTNEREXECUTIVE E,L. EACH ACCIDENT 3
OFFIGERMMEMBER EXCLUDED? NA f + a
(Mandatory in NH} Ell. OISEASE - EA EMPLOYEE $
Ifyes, describe undor — a oo
DESGRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT | $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Romarks Schedule, if moru space Is required)
Regarding the General Liability coverage, Blanket Additional Insured applies to the entities listed below per attached form GLS-150s when required by written
agreement,
Regarding the General Liability coverage, Waiver of Subrogation applies to the entities listed below per attached form CG 24 04 when required by written
agreement.
Blanket Primary & Non-Cantributory shown below is added per written agreement and form CG2001 attached to this policy
Additional insureds: Anthem Community Council Inc.; Anthem Parkside Community Association Inc,; Anthem eUTTy Club Community Association Inc.;
Maricopa County, State of Arizona, Daisy Mountain Fire Districl,; AAMLLC, their respective and affiliated entities and all of their respective directors, officers,
parinars, members, erployees, and agents are hereby named as additional insured. Insurance is primary and noncontributory. Display data is 03/12/2022
CERTIFICATE HOLDER CANCELLATION
SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
. ; ACCORDANCE WITH THE POLICY PROVISIONS,
Anthem Comma gre,
3701 W Anthem Way Ste #201
Anthem AZ 85086 AUTHORIZED REPRESENTATIVE
.
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
qconh CERTIFICATE OF LIABILITY INSURANCE ATE BOAT]
061022021 _
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND GONFERS NO RIGHTS UPON THE GERTIFICATE 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 PRODUGER, AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy{ies) must have ADDITIONAL INSURED provisions or be andarsed,
ff SUBROGATION IS WAIVED, subject to tho terms and conditlons of the policy, certain policies may require an endorsemont. A statement on
this certificate doos not confar rights to the certificate hotdor in liou of such endorsement(s).
PRODUCER Aenraet
Ryder, Rosacker, McCue % Huston fate io, tx
509 W, Koonig St. ‘AbaRESS: _
Grand Island NE 68801 INSUREA(S) AFFORDING GOVERAGH WANG
- InsuneR A, Travelers Assigned Risk =
INSuAES INSURER D ——
Randy Reyman dba JSSURER _
Any Pyro INSURER OS fo
INSURER B: {
sNsuyiuR H
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT TRE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIGY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHIGH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN |S SUBJEGY TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH P LIMITS SHOWN MAY HAVE DEEN REDUCED BY PAID CLAINS.
hell TYPE OF IHSURANCE ia = EDUEY ERE POLICY EXD ==
_ CORMERGIAL GENERAL LIABILITY "ACH OoCUIGENCE is
DAMAGE 1 RENTED | '
a
8
\t CLAMS MAGE | ObGUA
t REMIBES (Ea ocousents)
| : MED EXP (Ary ung parscny
— 8
ORNL AGGREGATE LAIT APS IES omtey | Is /
{ pag. | | = |
pouey |; bet L0G | &
| ounete: _ ————— - 3
| EORBINEO SINGLE LAT? |
| AUTOVORILA LABILITY ee {se mi
ay ALIO. | BODILY IeJLRY (Per parsey) | § —
baie ” 1 + i eal “1 AILEY [Per neciowntt! §
mane [RoE PERTY DAMAGE :
AUTOR, ¥ | AUTOS ONLY Afes accent) f
s
umorcua uaa | ooeug - $
[EXCESS UAB | om anenapatiy - $ =e
DEL HETENTIONS — = $
WORKERS COUPLSIIATION FER on
AND AMMLOYERS! LIARIITY vin «TS8uon, TER —
ANY PROPRIETORPARTNEREXECLTVE[ . . |, EAGHAGCIDENT 3.100.600
A \oercermenste excuneo. "| y | asa 6JUB-SRAG6IBS-21 12022 pSKwIIOR? | N 1s
{Mandatory la NK] LE} BISEASE- 2A exeLover! $ 100,000
Hyer. testabe wntor |
| DEECRIPTION OF DPC RATIONS togw it E1 binkase pansy unr -s $00,000
| |
| |
DESCRIPTION OF OPERATIONS MOGATIGNS (VEHICLES (AGOND 101, Additlonat fewmaihs Mahedulv, may bu oftacbod mare wosea 9 enquired
CERTIFICATE HOLDER CANCELLATION
4 HHOULD ANY OF THE ABOVE DESCRIBED POLICES DE CANCELLED BEFORE
Anthern Community Council THE EXPIRATION DATE THEREOF, NOVICE WILL BE DELIVERED IN
2707 W Anthem Way Ste #201 ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem, AZ 85084 AUTHOMZEN MPRESENT ATIVE “ <hitl>
© 1988-2015 ACORP CORPORATION. All righta rasorved.
ACORD 26 (2076103) The ACORD name and logo are registered matks of ACORD
LAUCH SITE |
our meg
om community park - Bing inipsviwww. ding con maps?qaantbenvt community parkdepes.,,
Br ee
Motes
Reyman Pyrotechniques/Any Pyro
Anthem- 3/12/2022
Content of display
Following is the shell content of the display:
21/2 inch shells-14
3 inch shells-72
4 inch shells-36
5 inch shells-24
‘ > A Rn
RANDY LL.
REYMAN
REY MAN PYROTECHNICQUES Oe ‘
City of Flagstaff Fire Department
211 W. Assen Avenue
Flagstaff, AZ, 86001
Pyrotechnics Porm
Parralt Molder: Randy Rayman
Issued By:
__Dato Issued:
Daisy Mountain Fire Prevention
41018 N Daisy Mountain Drive Anthem Az. 85086 623-465-7400 Feb. 1] 2022
Mr. Reyman,
Thank you for the submittal from Reyman Pyro-Techniques/Any Pyro requesting
to conduct the fireworks display for the Anthem’s Skate Park opening event on
March 12th 2022 and obtaining a DMFD permit for this event. Your site plan,
operator, and display 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 there is any extreme
wildfire conditions, extreme weather conditions, or if there is an active large-scale
emergency event the day of the event, DMFD may have to cancel the fireworks display.
We look forward to working with you again. Please let us know if you need any further
information.
Sincerely,
Dave Wiehen
Dave Nielsen — Assistant Chief’
Fire Prevention 623-465-7400