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: Thursday, July 2, 2026 at 8:30 pm

DISPLAY DIRECTOR (permit will be issued to the followin

Name: Greg Thomas 503-799-1902 Pro: |
Business: Fireworks Productions of Arizona Fax:
Address: 17034 S 54th St. Chandler AZ 85226 Email;

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.

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

PON>
PNPo

(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.

9 Wie F A J, J $1344 6/2/2026

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. INTHE 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

Z do
ACORD
.—

CERTIFICATE OF LIABILITY INSURANCE

DATE (MMIDDIYYYY)
5/11/2026

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 Great Lakes Partners Insurance Services PHONE |... FAX
223 West Grand River Ave #1 {ai No. Exs (AIC, No};
Howell MI 48843 ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Travelers Property Casualty Company of America 25674
INSURED . . . INSU : Third Coast Insurance Compan’ 10713
FPA, Ltd, DBA: Fireworks Productions of Arizona ————e P -
17034 § 54th St INSURER C : Allianz Global Corporate & Specialty SE
Chandler AZ 85226 INSURER D: Everest Indemnity Insurance Company 10851
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 678293842 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 [AODLSUBR POLICY EFF | POLICY EXP
fea TYPE OF INSURANCE INSR| wv POLICY NUMBER {MIMDDIVYYY) | (MMIDDIYYYY) LOAITS
B | GENERAL LIABILITY PYTPO000013-00 4019/2025 4019/2028 | EACH OCCURRENCE $1,000,000
rx] DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 500,000
] cLaIMS.MADE MED EXP (Any one person) | $
PERSONAL & ADVINJURY __| $ 4,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG | $ 2,000,000
pouicy | X | 89 | X | toc $
COMBINED SINGLE LIMIT
B | AUTOMOBILE LIABILITY PYTA0000009-00 4019/2025 tore‘2028 | COMBINED: $1,000,000
X | anv auro BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED
ALL OM [| SCHED BODILY INJURY (Per accident)| $
NON-OWNED PROPERTY DAMAGE :
HIRED AUTOS AUTOS (Pet accident)
$
c UMBRELLALIA8— | X | goour 25ABEX0150 4019/2025 1019/2026 | EACH OCCURRENCE 4,000,000
X | EXcEss LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
veo |__| rerentions s
A | WORKERS COMPENSATION ‘GJUB-1W11896-8-25(AZ) 401972025 rorsrozs |x | WESTATU.| [OR
AND EMPLOYERS’ LIABILITY vIn
ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? NIA
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE] $ 1,000,000
It 25, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 1,000,000
D | 2nd Excess GC10010017-251 40/9/2025 40/9/2026 | Each Occurrence 6,000,000
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 policies where required by written agreement.

Date of Display: July 2, 2026
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.

AU RIZED REPRESENTATIVE

wf =>

ACORD 26 (2010/05)

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

2 Class 2-A PresSurized
Water Fire Extiaguishers

Site Map Maximum Shell Size: 1.5” Basins eos, Letsure World

Fireworks Productions of Arizona 480-948-0090 info @fireworksaz.com

EXHIBIT A

LEISURE WORLD COMMUNITY

Maricopa County - Mesa

Thursday, July 2, 2026

7 —8 minute display

1,400 Basin Effects

This celebration contains a combination of fiery color and sparkling fireworks to thrill and
electrify the competitors, attendees and their guests.

7 - 8 Minute Aerial Basin Display:

Your Aerial Basin Display will contain a total of 1,400 aerial basin effects

1.5” - 14 FPA Premier Multi-shot Specialty Basins
(5 - 10 seconds between basins; pause before the GF)

(11 Multi-shot Basins fired one after another or together followed by 3 Multi-shot Basins fired
simultaneously for the Grand Finale)

Designed for the Leisure World Community by: Fireworks Pr roductions of Arizona

‘&

City of Phoenix
FIRE DEPARTMENT
FIRE PREVENTION SECTION

Pyrotechnician
Certificate of Fitness

Gregory Thomas

PY-00285

Expiration Date: 04/01/2029

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.

ay

John Mertens
City of Phoenix Fire Marshal

Callie Hunt (COB)

From: Victor Brown

Sent: Wednesday, May 27, 2026 11:12 AM
To: Cindy Herbel
Subject: Re: Fireworks - July 2 - Leisure World Community

We are aware of this display on July 2™ and have no objections.

Get Outlook for iOS

From: Cindy Herbe|

Sent: Friday, May 22, 2026 11:10:45 AM
To: Victor Brow!
Subject: Re: Fireworks - July 2 - Leisure World Community

Hello Victor,

Maricopa County has let me know that they won't put the display on their agenda until they have approval from
Rural Metro.

Please let me know if you need anything else from us.

If you have no objections please just send me an email that states ‘you are aware of the display and have no

objections’. | will be able to
forward that to Rual Metro

Cindy Herlel

Pyro Administrative
Assistant

Fireworks “7°
Productions
of Arizona
480-948-0090 (office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)

17034 S. 54th Street, Chandler, AZ 85226

From: Cindy Herbel

Sent: Thursday, May 21, 2026 2:51 PM

To:

Subject: Fw: Fireworks - July 2 - Leisure World Community

Hello,
| sent the below email to Ken and his auto response came back to send to you.

Would you be able to respond with any questions or let me know that Rural Metro has no objections so I'm able
to permit with Maricopa County asap.

Thank you so much.

From: Cindy Herbel

Sent:

To:

Subject: Fireworks - July 2 - Leisure World Community

Hello again,
Attached is the following for a fireworks display for Leisure World - Independence Celebration on
Thursday, July 2:

¢ 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.

May 21, 2026

Clerk of the Board of Supervisors
Maricopa County

301 W. Jefferson 10" Floor
Phoenix, AZ. 85003

To Whom It May Concern:

Attached is the permit application for Leisure World Community event
fireworks display scheduled for Thursday, July 2. Rural Metro Fire District
will be the responding fire department and I’ve emailed them to confirm that
they are aware of and have no objections to the display.

Once the permit has been approved with Maricopa County Board of
Supervisors please send me a copy either by mail or email to the following
address:

Fireworks Productions of Arizona
Attn: Cindy Herbel

17034 S, 54" Street

Chandler, AZ. 85226

If you have any questions or need any additional information, please do not
hesitate to contact my office. Thank you very much!

Pyrotechnically Yours,

Cindy Herbel
Pyro Office Assistant