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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 shali 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 lawiul 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 properly 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 (602-508-3766) 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
NamelOrganization: A\ wy-bhenn
Name of Event’ Maus Years Eue Veer on Ds. Noung
Eventaddress: Y(7103 Ale (ovilan Peaw Parkway, Budwn Az! 95086
Date and Time of Event!“ ec ember Bit 2020 @ ooPM ;
DISPLAY DIRECTOR (permit will be Issued to the following)
Name “Ranupy Réiymaat Phone
Business: RE, y > Fax:
Address:
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 86003
For questions, please call the Clerk of the Board of Supervisors at: 802-506-3766.
Received Time Oct, 15. 2020 12:17PM No. 7634
PAGE 62/@2
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
enaa
(North)
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
IT FOR FIR 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
—_ ® DATE (MMIDDIYYYY)
ACORD CERTIFICATE OF LIABILITY INSURANCE 1016/2020
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 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 GONTACT i cisty Wolfe _ _ ;
& Huston (MGD by Hull & Compa -— nr F
(AIC, No, Ext _ (AIC, Ni _
| ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
_ a insurer A: SCOTTSDALE IND CO. 15580
INSURER B : |
s / Any Pyro ;
INSURER C:
INSURER D :
INSURER E: |
INSURER F : |
COVERAGES CERTIFICATE NUMBER: 878407499 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,
LR TYPE OF INSURANCE ISR | WvD POLICY NUMBER (MMIDDIYYYY) | (MM/DDIYYYY) LIMITS
A | GENERAL LIABILITY CPIO064560 8/9/2020 8/9/2021 EACH OCCURRENCE $ 1,000,000
rx] DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 100,000
] CLAIMS-MADE MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY _| $ 1,000,000
| GENERAL AGGREGATE | $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
X | poucy BRO: Loc s
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Ea accident) $s
ANY AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED ,
Atos scree BODILY INJURY (Per accident)| $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
8
UMBRELLA LIAB occur EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE: | AGGREGATE $
DED. RETENTION $ $
WORKERS COMPENSATION We STATU- | [OTH-
AND EMPLOYERS’ LIABILITY YIN TORY LIMITS. __1.ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT s
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) | E.L. DISEASE - EA EMPLOYEE) $
if yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Blanket Additional Insured applies to the entities listed below per attached form GLI-150s when required by written agreement.
Waiver of Subrogation applies to the entities listed below per attached form CG 24 04 when required by written agreement.
Additional insureds: Anthem Community Council Inc.; Anthem Parkside Community Association Inc.; Anthem Country Club Community Association Inc.;
Maricopa County, State of Arizona, Daisy Mountain Fire District.; AAMLLC, their subsidiary and affiliated entities and all of their respective directors, officers,
partners, members, managers, employees, and agents are hereby named as additional insured. Insurance is primary & noncontributory
Display date is 12/31/2020
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
Anthem AZ 85086 AUTHORIZED REPRESENTATIVE
Au Ae
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE anne
—_
ACORD
——
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.
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
Ryder, Rosacker, McCue & Huston
INSURER(S) AFFORDING COVERAGE NAIC #
INsuRERA: Travelers Assigned Risk
INSURED INSURER B:
Randy Reyman dba INSURER C:
/Any Pyro INSURER D:
INSURER E:
| INSURER F :
COVERAGES CERTIFICATE NUMBER: 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.
[ADDL|SUBR| POLICY EFF | POLICY EXP
INSR TYPE OF INSURANCE INSD | wvD POLICY NUMBER (MMIDDIYYYY) | (MM/DDIYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
CLAIMS-MADE LJ OCCUR PREMISES (Ea occurrence) _| $
|__| MED EXP (Any one person) _| $
PERSONAL & ADV INJURY __| $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s
POLICY FBS Loc PRODUCTS - COMP/OP AGG | $
OTHER: s
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY | (eataecdents s
ANY AUTO BODILY INJURY (Per person) | $
OWNED, SCHEDULED
‘AUTOS ONLY AUTOS BODILY INJURY (Per accident) | $ |
HIRED. NON-OWNED PROPERTY DAMAGE $
|__| AUTOS ONLY AUTOS ONLY (Par accident)
$
UMBRELLA LIAB OccuR EACH OCCURRENCE $.
EXCESS LIAB CLAIMS-MADE AGGREGATE $
veo |_| retentions $
WORKERS COMPENSATION PER QTH-
AND EMPLOYERS! LIABILITY x [EFRure | [28 aaa
ANY PROPRIETOR/PARTNER/EXECUTIV E.L. EACH ACCIDENT. $
A |OFFICERIMEMBER EXCLUDED? NIA 6JUB~4N92392-4-20 06/01/2020 {06/01/2021 7
(Mandatory in NH) E.L. DISEASE - EA EmpLoyee| $ 100,000
If yes, describe under
DESGRIPTION OF OPERATIONS below ELL. DISEASE - Poticy Limit | s 500,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
|
CERTIFICATE HOLDER CANCELLATION
F i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Anthem Community Council THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
3701 W Anthem Way Ste #201 ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem, AZ 85086 <MM>
AUTHORIZED REPRESENTATIVE F
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
deus ana
3LIS HONW1
ithem community park - Bing
of 1
b bing maps
Notes
https://www.bing.com/maps?q=anthem+community+park&pe-...
/ Anthem
‘Caommunity=
Park
©
TAN INNIN 0.16 ANA
anthem shells
Reyman Pyrotechniques/Any Pyro
Anthem Display, 12/31/2020
Content of display
Following is the shell content of the display:
2 1/2 inch shells-42
3 inch shells-216
4 inch shells-144
5 inch shells-102
6 inch shells- 6
Page 1
» Uidexmational Mssaciation ©
of Bom Pesbointans —
& Investigators
MEMBER 1D:
RANDY L.
REYMAN
REYMAN PYROTECHNICQUES
City of Flagstaff Fire Department
211 W. Aspen Avenue
Flagstaff, AZ, 86001
Pyrotechnics Permit
Issued By: _f 22 OLtéck Fire Inspector
t —
Date Issued: (42 (A
Mail - RANDY REYMAN - Outlook
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RE: permit app
You replied on Thu 10/8/2020 2:32 PM
Thu 10/8/2020 2:
To: You
Hello Randy,
ba
Yes I received your application packet and will work on getting the
permit and letter out to you. I will email it to this address once it is
completed.
Respectfully,
Dave Nielsen
Asst. Chief - Fire Prevention
DaisyMountainFire.org
623-465-7400 x119
This e-mail message may contain confidential or privileged information for the sole use of the intended recipient(s). Any
review, use, disclosure or distribution by others is strictly prohibited. If you are not the intended recipient (or authorized to
receive it on behalf of the recipient), contact the sender by reply e-mail, and delete all copies of this message. Thank you.
From: RANDY REYMAI
Sent: Thursday, October 8, 2020 8:23 AM
To: Dave Nielsen|
Subject: permit app
Good morning Dave. | wanted to make sure you received my application for the Anthem NYE
display. | faxed it on Monday, 10/5.
Thanks,
Randy
Reply Forward
10/8/2020, 5:58 PM