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.
4. Verification from local fire department that they were notified of event, date, location and time.

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

Name of Event: Graduation

Event Address: 17608 W Olive Ave. Waddell, AZ 85355

Date and Time of Event: Tuesday, May 21, 2024 - following graduation approx 8:30pm

DISPLAY DIRECTOR (permit will be issued to the followin

Name: Kendon Victor Phone: —— #€=7+€&€Y|

Business: Fireworks Productions of Arizona Fax:

Address: 17034 S 54th St. Chandler AZ 85226 Email: i =|

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
APR 05 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

Pensa
PNEo

(North)

*@4email to Clerk of the Board

pe

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

DATE (MMIDDIYYYY)

— SS) 6
ACORD CERTIFICATE OF LIABILITY INSURANCE Emon

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
One Cleveland © OC IIwuwOqOo = kt _,
One Cleveland Center, Floor 30 {alc No. Ext {AIC, No =
ADDRESS: _|
INSURER(S) AFFORDING COVERAGE NAIC #
InsuRER A: Everest Indemnity Insurance Co. 10851
INSURED INSURER B : Axis Specialty Ins Co 15610
FPA, Ltd. -
17034 S 54th St INSURER c : Everest Denali Insurance Company 16044
Chandler AZ 85226 INSURER D : AZ Assigned Risk Plan NCCI
INSURER E:
INSURER F :
COVERAGES CERTIFICATE NUMBER: 1994746108 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
LIR TYPE OF INSURANCE INSR| WD. POLICY NUMBER MMIDDIYYYY) | (MM/DDIYYYY) LIMITS
‘A | GENERAL LIABILITY y | y | sisGvoz238-231 40/9/2023 401912024 | EACH OCCURRENCE $ 4,000,000
DAMAGE TO RENTED
X | COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 500,000
CLAIMS-MADE OCCUR MED EXP (Any one person) _| $
PERSONAL & ADV INJURY _| $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG | $2,000,000
pouicy | X | SBS Loc §
COMBINED SINGLE LIMIT
C | AUTOMOBILE LIABILITY Y | y | siscacoass-231 10/9/2023 10172024 | GOMBINEY S 4,000,000
X | ANY AUTO BODILY INJURY (Per person) | $
auros |_| AuToS BODILY INJURY (Per accident) | $
X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
B UMBRELLALIAB | X | occuR Y | y_ | P-001-000691697-02 40/9/2023 10192024 | EACH OCCURRENCE § 4,000,000
X | EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
DED. | l RETENTION S S
D | WORKERS COMPENSATION 6JUB-6RO8411-5-23(AZ) 10/9/2023 40/9/2024 |X | WOSTATU- OTH-
AND EMPLOYERS’ LIABILITY YIN ) roevuarsl [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
Ifyes, describe under
DESCRIPTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT | $ 1,000,000
A | 2nd Excess SI8EX01790-231 40/9/2023 40/9/2024 | 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: May 21, 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

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

American Leadership Academy West Foothills 7-12 ACCORDANCE WITH THE POLICY PROVISIONS.

17608 W Olive Ave
Waddell AZ 85355 AUTHORIZED REPRESENTATIVE

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

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EXHIBIT A

AMERICAN LEADERSHIP

ACADEMY- WEST FOOTHILLS
WADDELL

Tuesday, May 21, 2024
Graduation

2 minute display

Total Aerial Effects 232

In celebration of the Class of 2024 Seniors, a spectacular display of
fiery Red, White and Blue in the sky following graduation.

Opening: 2 — 100mm Colored Mines
Aerial Display:
84 — Comets will rise up as individual fiery balls of color.
116 — Crossettes criss-crossing in the air bursting into a multitude of
Red, Silver and Blue colors.
8 — Bombettes will fire in multiple volleys of glowing color.
2 — Large Color Mines burn brightly, high into the sky.
Grand Finale:
2 — Large Color Mines
16 — Color Crossettes
2 - Large Glitter Crackle Mines

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 8105.11.
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: Diamond, Kenneth

Sent: Friday, April 5, 2024 2:18 PM
To: Cindy Herbel
Subject: Re: Fireworks - ALA Foothills - May 21

| am aware and approve.

Thank you

Kenneth Diamond
Fire Marshal
Fire Plans Examiner

Central Arizona Fire —

(480) 869-2340

<.) RURAL
METRO

A Global Medical Response Solution

www.ruralmetrofire.com

| Certified :
firePlans
Examiner

From: Cindy Herbe!| iin

Sent: Friday, April 5, 2024 1:46:01 PM

To: Diamond, Kennet i

Subject: EXT: Fireworks - ALA Foothills - May 21

ATTENTION: External Email — Use Caution — Contact Phishing@gmr.net if suspicious.

Hello there!
One more graduation and because you are the guy for all of the valley - here you go!
Attached is the following for a graduation display American Leadership Academy West Foothills in Waddell AZ on
Tuesday, May 21:
e Rural Metro Notification
e Show Program

e Site Map
e COl

When you get a chance please let me know if you have any questions or objections to this display so! can
submit to Maricopa County.

Thank you and have a great weekend!

Cindy Herbel

Pyro Administrative
Assistant

Fireworks
Productions
of Arizona

480-948-0090 (office)
480-423-8430 (fax)
1-877-948-0090 (toll-free)

17034 S, 54th Street, Chandler, AZ 85226

April 5, 2024

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 American Leadership Academy ~ West
Foothills in Waddell for graduation fireworks scheduled for Tuesday, May 21,
2024 . Rural Metro Fire District will be the responding fire department.

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