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: New Year's Eve Fireworks

Event Address: 908 S. Power Road, Mesa AZ 85206

Date and Time of Event: December 31, 2020 @ 10:30pm

DISPLAY DIRECTOR (permit will be issued to the following)

Name: Cody Welty Phone: |
Business: Fireworks Productions of Arizona Fox:

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 Mave
NOV 2 0 2020

MARICGPA COUNTY
CLERK BOARD OF SUPERVISORS

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

Pens
PN

(North)

See Attached

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

ERMIT 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

EXHIBIT A

LEISURE WORLD COMMUNITY

Mesa
New Year’s Eve
10:30 pm

Thursday, December 31, 2020

6 - 8 minute display

Total Aerial Effects 419
Total Shells 219 Total Effects in Basins 200

Opening:
Leisure World's fantastic celebration of the New Year begins with an impressive
series of powerful booms and fiery, gorgeous color to excite and thrill your guests.

7 - 3” Color Shells

Aerial Display:

A large assortment of brilliantly-colored shells, including Chrysanthemums, Waves,
Crowns, Peonies, Brocade Crowns, Diadems, and Crossettes in gorgeous Reds,
Yellows, Blues, Greens, Silvers, and Golds.

Your Aerial Display will contain a total of 163 aerial shells and 200 basin effects.

1%’ - 2 FPA Premier Specialty Basins
3” - 163 Chinese Fancy’s & Specials

Grande Finale:

Your celebration will close in spectacular excitement as multiple styles of brilliantly-
colored shells, rocket skyward growing and glowing in breath-taking Blues, Golds,
Greens, Silvers, Yellows, Purples and Red.

Your Grande Finale consists of 49 — 3” aerial shells.

Designed tor the [ eisure World Ce ommunity by: Fireworks P; toductions of Arizona

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ACORO” CERTIFICATE OF LIABILITY INSURANCE eae

11/12/2020
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 bolicy(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 fleu of such endorsement(s).

PRODUCER GONTACT net Nau
The Partners Group Ltd PRONE FAX
11225 SE 6th St., Suite 110 (ale, Ni ALC, No
Bellevue WA 98004 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: T.H.E. Insurance Company 12866
EPA LTD 16021) isureRB : Travelers Property Casualty Co of America 25674
Fireworks Productions of Arizona INSURER C:
17034 S. 54th Street INSURER D:
Chandler AZ 85226 INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: 953448588 REVISION NUMBER:

ADDL]SUBR] POLICY EFF | POLICY EXP
ey TYPE OF INSURANCE INSR|WyD POLICY NUMBER (MMIDD, (MM/DDIVYYY) LIMITS
A | GENERAL LIABILITY Y CPP010586204 40/9/2020 1098/2021 | EACH OCCURRENCE $1,000,000
x] DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $500,000
| CLAIMS-MADE OCCUR MED EXP (Any one person) S$ NIA
X | s2000 Deductible PERSONAL & ADV INJURY _| $ 4,000,000
GENERAL AGGREGATE $ 10,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | § 2,000,000
X | poucy[ | SRO Loc $
A | AUTOMOBILE LIABILITY CPP010586204 10/9/2020 to/si2021 | ROMBINED SINGLE LIMIT $1,000,000
ANY AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED
X | HIRED auTos AUTOS Per accident 8
aa | (Per accident)
$
A UMBRELLALIAB | X | occur ELP001232904 10/9/2020 10/9/2021 | EACH OCCURRENCE $9,000,000
KH -—
X | EXCESS LIAB CLAIMS-MADE AGGREGATE $9,000,000
veo |_| RETENTION $ $GL Only
B_ | WORKERS COMPENSATION 1K643590 10/9/2020 1079/2021 |x | WOSTATU- OTH-
AND EMPLOYERS’ LIABILITY YIN [TRV Tis ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L, EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? LJ NIA
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE] $ 1,000,000
if yes, describe under
DESGRISTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT | § 1,000,000
A | Auto Excess Liability - Ocourrenc ELP001291102 10/9/2020 10/9/2021 | Each Occurrence 4,000,000
Aggregate 4,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 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 contract:

Date of Display: December 31, 2020

Location of Display: Coyote Run Golf Course at Leisure World Community, Mesa

Additional Insured(s): State of Arizona; Maricopa County; Rural Metro Fire Department; Leisure World Community Association; Coyote Run Golf Course.

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.

Leisure World Community Association

p08 S. Power qeond AUTHORIZED REPRESENTATIVE

I

© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD

From:

Sent:

To:

Subject: RE: EXT: Fireworks - Dec 31- Leisure World

cindy @fireworksaz.com
cm —_ 17,2020 9:50 AM

Hi Cindy

My office is aware of the fireworks shoot and we are responsible for that area. We have no issues with the setup and
shoot.

Thank you

Kenneth Diamond
Fire Captain
Deputy Fire Marshal

Rural/Metro Fire Central Arizona

7631 E. Main St Mesa, AZ 85207
C: 480.869.2340
O: 480.380.3700 x Option 4

From:

Sent: Thursday, November 12, 2020 12:

Subject: EXT: Fireworks - Dec 31- Leisure World

Hello,

Hope all is well with everyone there at Rural Metro!

Attached is the Permit Request for a New Year’s Eve display at Leisure World. We are getting ready to send in for the
Maricopa County permit and they require a letter from you stating that you are aware of the fireworks display. Please
let me know if you have any questions.

Attachments: Request Letter
Show Program
Site Map
col

Cinaly Herbie

Pyro Administrative
Assistant

‘Fireworks a
Productions
of Arizona

480-948-0090 (office)
480-423-5430 (fax)

1-877-948-0090 (toll-free)
17034 S. 54th Street, Chandler, AZ 85226

Virus-free. www.ava.com

RURAL/METRO FIRE DEPARTMENT
PERMIT MARICOPA OPERATIONS
FIRE PREVENTION

9221 E Via de Ventura
Scottsdale, AZ 85258
(602) 677-4421 phone (480) 627-6249 fax

For the keeping, use, storage, manufacture, handling, transportation or other disposition of flammable,
combustible, explosive or otherwise hazardous materials, or maintaining a place of assembly, institutional
or educational occupancy

PERMIT #: ISSUE DATE: EXPIRE DATE:
2020-MC-BM-0001 12/31/2020 01/01/2021
BUSINESS NAME: CONTACT:

Fireworks Productions of Arizona Cindy Herbel

ADDRESS:

17034 S. 54th Street Chandler, AZ 85226

EVENT:
SITE: ADDRESS:

Leizure World 908 S. Power Road, Mesa, Az. 85206
DATES OF EVENT:

12/31/2020 - 12/31/2020

Call 602-677-4421 for an inspection a minimum of 72 hours prior to the event. Two inspections are
included with the permit, any additional inspections may result in additional fees charged.

Having made application in due form, is hereby granted this permit for:

FIREWORKS

Outdoor pyrotechnics must provide a safe fall-out area per IFC and NFPA standards.

Indoor pyrotechnics must be a minimum of 15 ft. from the audience.

Concussion morters shall be a minimum of 25 ft. from the audience.

Provide two or more Fire Extinguishers within 50 ft. of the display.

Chemical Fog machines shall be a minimum of 15 ft. from the audience.

You must conform with the International Fire Code, 2003 ed., NFPA 1123, 1124, 1126 and Ord.

Call the Rural/Metro Comm Center at 480/945-6311 before and after all outdoor fireworks programs.
A Fire Dept. standby is required for all pyrotechnics programs at a charge according to published fee
rates.

This permit may be cancelled by the fire department at any time.

A copy of the permit is required to be on site at all times.

Please sign and return this permit via FAX at 480-627-6249 for permit to be valid.

This permit is issued and accepted on condition that all regulations now adopted, or which hereafter may
be adopted, shall be complied with. This permit does not take the place of any license or other permit
which may be required by law, and is not transferable. Any change in ownership, use or occupancy of the
premises shall require a new permit.

Permittee: Issued by:
Title: Title: