AMERICAN LEADERSHIP ACADEMY-WEST FOOTHILLS 7-12_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.
Verification from local fire department that they were notified of event, date, location and time.

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EVENT INFORMATION
Name/Organization: | American Leadership Academy - West Foothills 7-12

Name of Event: Homecoming/Senior night football game
Event Address: 17608 W Olive Ave. Waddell, AZ 85355

Date and Time of Event: Friday, October 25, 2024 - pregame 6:45pm - end of game approx 9:30pm

DISPLAY DIRECTOR (permit will be issued to the following)
Name: Kendon Victor Phone: —_
Business: Fireworks Productions of Arizona Fax:

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

Pens
PN OA

(North)

email 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)
9/13/2024

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 CONTACT

Acrisure, LLC dba Britton Gallagher & Associates E

3737 Park East Dr. STE 204 ec {ale Wo, Ext): 216-658-7100 FAB. Noy: 216-658-7101
Beachwood OH 44122 ADDRESS:

| INSURER(S) AFFORDING COVERAGE NAIC #
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: 334267351

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 (MM/DDIYYYY) | (MM/DDIYYYY) LIMITS
A | GENERAL LIABILITY y | y | siscio2238-241 101912024 10/9/2025 | EACH OCCURRENCE $1,000,000
xX DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $500,000
| CLAIMS-MADE OccuR MED EXP (Any one person) _| $
PERSONAL & ADVINJURY __| $ 1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG | $ 2,000,000
POLICY BBO Loc $
COMBINED SINGLE LIMIT
8 | AUTOMOBILE LIABILITY y | y | siscaoo2ss.241 40/9/2024 yoriz025 | COMBINED § $4,000,000
X | any AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED ,
Kee Re co PROPERTY CANAGE fe
X | nireo autos |X | autos (Per accident) s
§
c UMBRELLALIAB | X | occur Y | Y | P-001-000691697-04 10/9/2024 1019/2025 | EACH OCCURRENCE $ 4,000,000
X | EXCESS LIAB CLAIMS-MADE, AGGREGATE $
DED l [ReTENTIONS $
D_ | WORKERS COMPENSATION 6JUB-1W11896-8-24(AZ) 40/9/2024 10/9/2025 |X | WOSTATU- l OTH-
AND EMPLOYERS’ LIABILITY YIN TORY LIMIT ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L. 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 ‘SIBEX01790-241 10/9/2024 10/9/2025 | 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: October 25, 2024
Location of Display: ALA West Foothills 7-12 Waddell AZ

Additional Insured(s): State of Arizona; Maricopa County; Rural-Metro Fire Department; American Leadership Academy West Foothills 7-12.

CERTIFICATE HOLDER

CANCELLATION

American Leadership Academy West Foothills 7-12
17608 W Olive Ave

Waddell AZ 85355

USA

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

WA

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

AMERICAN LEADERSHIP

ACADEMY- WEST FOOTHILLS
WADDELL

Friday, October 25, 2024

Homecoming/Senior Night
Total Aerial Effects 132

Aerial Display of Close Proximity Pyrotechnics:

Your Aerial Display will contain a total of 132 Aerial Effects.

American Leadership Academy - West Foothill’s show to consist of:

TEAM INTRO (TEAM ENTRANCE Is 6:401SH)
2-8 SHOT X 6 SEC. FINALE BOMBETTE BOARDS (RED & BLUE)
2 - 8 SHOT X 6 SEC. FINALE CRACKLE COMET BOARDS

NATIONAL ANTHEM
2 - LARGE MINES (RED)
ROCKETS’ RED GLARE
2-1 SHOT RED BOMBETTE
BOMBS BURSTING
2 - 8 SHOT X 6 SEC. FINALE BOMBETTE BOARDS (RED/WHITE/BLUE)
HALF-TIME KING & QUEEN
2.- 8 SHOT X 6 SEC. FINALE BOMBETTE BOARDS (BLUE & RED)
KING, THEN QUEEN, FIRE AFTER QUEEN

SCORE SHELLS
4-3 SHOT FAN CROSSETTE BOARD
(RED/BLUE/RED) (10 Scores TOTAL)

END OF GAME
2 - 8 SHOT X 6 SEC. FINALE BOMBETTE BOARD (RED & BLUE)
2. - 8 SHOT X 6 SEC. FINALE CRACKLE COMET BOARD
2 - LARGE MINES (RED/BLUE)
(All remaining score shells fired at end of game)

Designed for American Leadership Academy by: Fireworks Productions of Arizona

City of Phoenix
FIRE DEPARTMENT
FIRE PREVENTION SECTION

Pyrotechnician
Certificate of Fitness

Kendon Victor

PY-00215

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.

en

John Mertens
City of Phoenix Fire Marshal

Fireworks Productions of Arizona

17034 S. 54" STREET
CHANDLER, ARIZONA 85226
(480) 948-0090 FAX (480) 423-5430

FIREWORKS NOTIFICATION LETTER

September 13, 2024

TO: Rural Metro Fire Department

FAX: 480-998-0877

ATTN: Kenneth Diamond

We would like to notify you of the following fireworks show:

Name of Client:

American Leadership Academy West Foothills 7-12

Show Date & Time: October 25, 2024

Show Address:

Max. Shell Size
Site Map:
Insurance:
Shooter:

1st shot for Team Intro

2"4 shot for National Anthem
Score Shells

King/Queen

End of Game

ALA — West Foothills

17608 W Olive Ave
Waddell, AZ 85355

1.4G pyro — 132 total effects
Attached

Attached

Kendon Victor oO =i

Mia Vargas (COB) -

EIS aE eo SSeS
From: Diamond, Kenneth
Sent: Thursday, September 19, 2024 11:11 AM
To: Cindy Herbel
Subject: Re: Fireworks - Oct 25 - ALA West Foothills (Waddell)
Hello
Approved

Kenneth Diamond
Fire Marshal
Fire Plans Examiner

Central Arizona Fire Operations

(480) 869-2340

Certified

Fire Plans
Examiner

From: Cindy Herbel <cindy@fireworksaz.com>
Sent: Thursday, September 19, 2024 10:35 AM

To: Diamond, Kenneth

Subject: EXT: FW: Fireworks - Oct 25 - ALA West Foothills (Waddell)

Hello there,

Please see below for the ALA West Foothills game on Oct 25. I’m needing to submit to Maricopa County for the
permit and I’m sure it’s needing to get in soon so it can get on their calendar. ls there someone else this should
goto now since it is on the West side.

| know I’m probably requesting this (and the one I’m about to send for Leisure World) during a busy time, you are
everywhere!

Pyro Administrative
Assistant

Fireworks i
Productions i)

of Arizona

480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0080 (toll-free)

17034 S. 54th Street, Chandler, AZ 85226

From: Cindy Herbel
Sent: Friday, September 13, 2024 3:02 PM

To: Diamond, Kennet

Subject: Fireworks - Oct 25 - ALA West Foothills (Waddell)

Hello again,
Attached is the following for a fireworks display for ALA - West Foothills school’s homecoming and senior night
display on Friday, October 25, 2024 in Waddell:

e Notification letter

e Show Program

e Site Map

e 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.

Thank you and have a great weekend!

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