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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 praperty 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. Afler 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 thal the governing body shall require each applicant to provide a satisfactory bond of
nat 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:New Years Eve Firework Display
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086
Date and Time of Event: December 31st, 2021 @ 8:00 PM
DISPLAY DIRECTOR (permit will be issued to the following)
Name-Randy Reyman i _—
Business:R 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:
1. North direction 5. Fire department access
2. Distance from firing area to impact/fallout area 6. Hydrants
3. Spectator location 7. Distance to structures
4. Storage area 8. Overhead lines
(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
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
— ®
ACORD
‘ a
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIVYYY)
91912021
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
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,
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
certificate holder in lieu of such endorsoment(s).
IMPORTANT: I[f the cartlficate holder is an ADDITIONAL INSURED, tho policy(ies) must be andorsed. If SUBROGATION IS WAIVED, subjact to
the terms and conditlons of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
PRODUCER
Ryder Rosacker IicCue & Huston (MGD by Hull & Compa
509 W Koenig St
Grand Island NE 68802
CONTACT
WANE: Kristy Wolfe 7
IAG, No, Exth
E-MAIL
i :
INSURED
f “
a INSURER(S) AFFORDING COVERAGE : HAIG &
iNsuRER A: SCOTTSDALE IND CO B58
INSURERS : oo _—
INSURER Cs _ — —
INSURER
| NSURERE: ee
INSURER E:
COVERAGES CERTIFICATE NUMBER: 1205239695
REVISION NUMBER;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION GF 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 HAY! REDUCED BY PAID CLAIMS,
is "ADDE'SUBRE ~T RaLIGY Efe | PoLicy EXP 7
SR TYPE OF INSURANCE ANSE WUD POLICY NUMBER AMDOIVYYYE mao erY) . Liears
A | GENERAL LIABILITY i SPIGOSISES ig/2624 ameoee | gary occuanence § 1,000,020 __
= ORENTED
X | COMMERCIAL GENERAL LIABILITY PREMISES {Ev occurrence, | § 190,009 _
|) ctamswoe |X | occur EXP {any ono porsen) | $5,c00 _
Oe NAL BALY INJURY — | $ 1,000,000 _|
GENL AGGREGATE LIMIT APPLIES PER: PRODUGT:! $ 2,009,c00
EX leoucy| [68% [voc
T AUTOMOBILE LIABILITY
ANYAUTO |
7) ALL OWNED SCHEOULED /
|__| AUTOS [al _
NON-GWKED
|_| HIRED AUTOS |__| AUTOS /
|
UMBRELLA LIAB DtCUR
EXCESS LIAB CLANS NAADE :
on | Lactennions
WORKERS COMPENSATION WG STATI. TOFH.
AND EMPLOYERS" LIABILITY vN [ravings] IR
ANY PROPRIETOUPARTNER/ENECU TIVE } E,L, EACH ACCIDENT $
CFRICERMENBER EXCLUBED? NTA
(Mattdatory in NH} E,L_ DISEASE - EA EMPLOYEE! $
Ityas, deacrite undee 2
DESCRIPTION OF OPERATIONS tatay E.1 DISEASE - POLICY LIM 1S
agreement.
agreement.
Additional insurads: Anthem Community Council inc., Antharn Parkside
DESCRIPTION OF OPERATIONS f LOCATIONS / VEHICLES {Attach ACORD 161, Additional Romarks Schodule, If more space Is roquired)
Regarding tha General Liability caverage, Blanket Additional Insured applies to the entities listed below par attached form GLS-150s when required by written
Regarding the General Liability coverage, Waiver of Subrogation applies to the entities listad belaw per attached form CG 24 04 when required by written
Blanket Primary & Non-Contributory shown belaw is added per written agreement and farm GG2001 attached to this policy
ammunity Association inc.; Anthem Country Club Community Association Inc.;
Maricopa County, State of Arizona, Daisy Mountain Fire District; AAMLLC, their respective and affiliated entities a
pariners, members, employees, and agents are hereby named as additional insured. Insurance is primary and noncontributory, Display date Is 12/31/2021
ail of their respective directors, officers,
CERTIFICATE HOLDER
CANCELLATION
Anthem Community Council
3701 W Anthem Way Ste #2014
Anthem AZ 85086
SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Now Drea
ACORD 25 (2010108)
© 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD
Nee
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYY)
06/02/2021
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the p
If SUBROGATION IS WAIVED, subject to the terms and conditions of th
this certificate does not confer rights to the certificate holder in liau of such endorsement(s).
olicy(ies) must have ADDITIONAL INSURED provisions or be endorsed,
@ policy, certain policies may require an endorsement. A statement on
TACT
PRODUCER | ANE
509 W, Koenlg St, ABDRESS: =
Grand Island NE 68801 INSURER(S) AFFORDING COVERAGE NAIC
a _— | waunena: Travelers Assianed Risk
INSURED JINSURERB:
Randy Reyman dba LINSURER ©: —_
Reyman Pyrotechniques/Any Pyro INSURER O —
INSURER Et a al
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORD!
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIGD
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
INSR] JAODL[SuaR| POLIG _
Lik. TYPE OF INSURANCE POLICY NUMBER RUDDY IRMA YP LIMITS.
COMMERCIAL GENERAL LIAGILITY EAGH OCCURRENCE a
ey 7
| CLAIMS.MAgE [ ] OCCUR | | PREMISES (ea ceaurrenn, —|3.
JJ - _ MED EX? (Any ana porsan) | $_ |
: PERSONAL & ADVINJURY | $ aes
JEN. AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE 3
Pouicy ES Loc PRODUCTS - COMPIOP AGG | $s
OTHER: 3
AUTOMOBILE LIABILITY [ FENERES SNOLE UAT Ts
|__| ANY AUTO BODILY INJURY (Per person) i$
OWNED SCHEDULED f
| | oeeer oy |_| Saree BODILY INJURY (Par accidant)| §
HiREG NOW-AVNED PROPERTY DAMAGE $
-—] AuTosanty — |_| AUTOS CNLY | (eer accidents
s
UMBRELLALIAB | | occur EAGH COCURRENGE ef
EXCESS LIAB CLAIMS-MAtE| AGGREGATE $_. _
Lorn | | netewtions 3
WORKERS COMPENSATION PER On
AND EMPLOYERS’ LIABILITY fe x [Bffure | Tee +
ANY PROPRIETORIPARTNERNEXECU TIVE, EL EACH ACCIDENT s 100,000
A OFFICER MENSER EXCLUDED? Y}NIA 6JUB-5R85638-5-21 60112021 (06/01/2022
) (Mandatory In mit & | DISEASE - EA EMpLoyee! s 100,000
yes, desevibe uni
RESEAIPSION OF OPERATIONS tolow LE |. DISEASE -PoLIcy um | s 500,000
DESCRIPTION OF OPERATIONS / LOGATIONS / VEHICLES (ACORD 101, Additional Ramarks Schoo
iulo, may bo akached if more space is roquired)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Anthem Community Council THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
3707 W Anthem Way Ste #201 ACCORDANCE WITH THE POLICY PROVISIONS.
Anthem, AZ 85086 AUTHORIZED REPRESENTATIVE ; <NM>
Hontshi
i
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved,
The ACORD name and Jogo are registered marks of ACORD
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Notes
httpsviwww.bing.com/maps?q=anthem+community+park&po=.,,
anthem shells
Reyman Pyrotechniques/Any Pyro
Anthem Display, 12/31/2021
Content of display
Following is the shell content of the display:
2 1/2 inch shells-14
3 inch shells-72
4 inch shells-72
5 inch shells-36
6 inch shells- 2
Page 1
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MEMBER iii
RANDY LL.
REY MAN
REYHAN PYROTECHNICQUES oT
CiAG Keaton:
; ‘ City of Flagstaff Fire Dopartnont
} 211 W. Aspon Avenue
Flagstaff, AZ, 86001
Pyrotechnics Permit
Permit
D i 7)
DAISYMOUNTAIN
41018 N DAISY MOUNTAIN DR
ANTHEM, AZ 85086
Permit Certificate DMFD
Date: 10/20/2021
Business Name: ANY PYRO
Address; 41130 N FREEDOM Wy
ANTHEM, AZ 65086
Phone: OFFC 602~448-1033
The following permit has been issued:
Permit No. 21-000892 Type: FIREWRKS FIREWORKS SALES/DISPLAY
Issued Date: 10/20/2021 OCCUPANT LOAD: i
Effaative Date: 12/30/2021
Expiration Date; 01/01/2022
Notes:
ANYPY
RANDY
ANTHEM FIREWORKS DISPLAY AT 41130 N FREEDOM WAY. ANTHEM AZ 85086
it is the business's responsibility to ensure that conditions are in
accordance with applicable State and Local fire regulations.
Obtain any permits that are required by the State of Arizona and the County
having jurisdiction. Seng.
G _paisy *
Inspector: DMFD SIRE PREVENTTOPOUNIANT Date 10/20/2021
10/20/2021 12:37 Page i