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:
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: Leisure World Community

Name of Event: Community Event

Event Address: 908 S Power Rd. Mesa AZ 85206

Date and Time of Event: Monday, November 11, 2024 @ 6:45pm

DISPLAY DIRECTOR (permit will be issued to the following)

Name: Todd Schumacher Phone: 480-948-0090 office
Business: Fireworks Productions of Arizona Fax: 480-423-5430
Address: 17034 S 54th St. 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 19 2024

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

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

PONS
OPNOn

(North)

: egjemail to Clerk of the Board

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

@®
ACORD
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CERTIFICATE OF LIABILITY INSURANCE

DATE (MMIDDIYYYY)
9/16/2024

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
Acrisure, LLC dba Britton Gallagher & Associates
3737 Park East Dr. STE 204

CONTACT
NAME:

PHONES ext). 216-658-7100 IRS, No}: 216-658-7104

Beachwood OH 44122 ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #
s INSURER A : Everest Indemnity Insurance Company ___ 10851
EPA, Ltd, DBA: Fireworks Productions of Arizona INSURER B : Everest Denali Insurance Company 16044
17034 S 54th St INSURER c : AXIS Surplus Insurance Company 26620
Chandler AZ 85226 INSURER D: Travelers Property Casualty Company of America 25674

INSURER E:

INSURER F :

COVERAGES CERTIFICATE NUMBER: 910907108

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 INSR| WVD. POLICY NUMBER (MMIDDIYYYY) | (MM/DDIYYYY) LIMITS
A. | GENERAL LIABILITY Y | Y | siscio2238-241 40/9/2024 10/9/2025 | EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X | COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) __| $ 500,000
| CLAIMS-MADE OCCUR MED EXP (Any one person) _| $
PERSONAL & ADV INJURY ___| $4,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
POLICY ied Loc $
COMBINED SINGLE LIMIT
B | AUTOMOBILE LIABILITY Y | Y | Slscaao2s8-241 10/9/2024 torsiz025 || GOMBINED S $4,000,000
X | any AUTO BODILY INJURY (Per person) | $
ALL OWNED [| SCHEDULED BODILY INJURY (Per accident) | $
NON-OWNED PROPERTY DAMAGE
X | HIRED AUTOS AUTOS (Per accident) $
$
c UMBRELLALIAB— | X | occur y | Y | P-001-000691697-04 10/9/2024 10/9/2025 | EACH OCCURRENCE $ 4,000,000
X | EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED | | RETENTION S. $
D_ | WORKERS COMPENSATION 6JUB-1W11896-8-24(AZ) 10/9/2024 1012025 |X | WOSTATU. OTH-
AND EMPLOYERS!’ LIABILITY YI Kaz) TORY. LIMIT: | ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) ELL. DISEASE - EA EMPLOYEE] $ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 1,000,000
A | 2nd Excess SI8EX01790-241 40/9/2024 40/9/2025 | Each Occurrence 5,000,000
Aggregate 5,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks 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, 2024
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

Leisure World Community Association
Finance Department

908 S. Power Road

Mesa AZ 85206

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

By”

ACORD 25 (2010/05)

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

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EXHIBIT A

LEISURE WORLD COMMUNITY

Mesa
Monday, November 11, 2024
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)

Designed tor the | eisure World Community Ly: Fireworks Productions of Arizona

City of Phoenix
FIRE DEPARTMENT
FIRE PREVENTION SECTION

Pyrotechnician
Certificate of Fitness

Todd Schumacher

PY-00216

Expiration Date: 04/05/2027

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.

John Mertens
City of Phoenix Fire Marshal

Mia Vargas (COB)

=== ae
From: Diamond, Kenneth
Sent: Thursday, September 19, 2024 11:11 AM
To: Cindy Herbel
Subject: Re: Fireworks - Nov 11 - Leisure World
Hello
Approved

Kenneth Diamond
Fire Marshal
Fire Plans Examiner

Central Arizona Fire —

(480) 869-2340
+ RURAL
METRO

www.ruralmetrofire.com

Certified

Fire Plans
Examiner

From: Cindy Herbel <cindy@fireworksaz.com>
Sent: Thursday, September 19, 2024 10:37 AM

To: Diamond, Kennet}

Subject: EXT: Fireworks - Nov 11 - Leisure World

Hello again,
Attached is the following for a fireworks display for Leisure World - Veteran’s Day display on Monday, November
11, 2024:

e Notification letter

e Show Program

e Site Map

e cCOl

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

1

Cindy Herbel

Pyro Adminisirative
Assistant

Fireworks
Productians |

480-948-0090 (office)
480-423-5430 (fax)
4-877-948-0090 (toll-free)

17034 5. 54th Street, Chandler, AZ 85226