ANTHEM APPLICATION OF FIREWORKS DISPLAY_REDACTED.PDF

Maricopa County — Formal (2024-04-10)

Extracted text (via ocr_local) 8516 characters

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 handied oy 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. After a
permii is granted, the sale, possession, use and distribution of firewarks 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 usuelly 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 oe 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: July 3rd, 2024 Fireworks Display |
Event Address:41130 N. Freedom Way, Phoenix, AZ. 85086
Date and Time of Event: July 3rd., 2024@ 9:00 PM

DISPLAY DIRECTOR (permit will be issued to the following)

_Business:Reyman Pyrotechniques/Any Pyro | Fax: i

SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO:

Maricopa County Clerk of the Board of Supervisors Email: ClerxBoard@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 §. Fire depariment 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
MAR 9 1 2024

MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS

(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. § 38-1603, 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 (7) 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

— SY 3 “n BATE (MI/DDIYYYY]
ACORD CERTIFICATE OF LIABILITY INSURANCE 1912772008

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 ta
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate dees not confer rights to the

certificate holdar In llau of sush endorsemeni{s).

eneOuCRR Rane Kesty Wolle

Ryder Rosacker, McCue & Huston (MGD by Hull & Company)
508 W Koenig
Grand Island ce 68801

_______INSURER(5) AFFORDING COVERAGE NAIC
—_ neurer a: SCOTTSDALE IND CO 15580
INSURED
Reyman Pyrctechniques / Any Pyro SURE ae oo
12820 S. 40th Place INSURER ¢:
Phoenix AZ 85044 HSURER ©:
INSURER & :
INSURER EF: _
COVERAGES CERTIFICATE NUMBER; 1138061082 REVISION NUMBER:

THIS IS TO CERTIFY THAT TRE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEO TO THE INSURED NAMED ABOVE FOR THE SOLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOGUMENT 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 SHOWIN MAY HAVE BEEN REOUCED BY PAID CLAIMS,

“TAODLSUBR™ | POLICY EXP ——
NR TYPE OF INSURANCE eo uBR POLICY KUMBER LMSD BAY | nee) VEY YL: LMITS.
| SPLICE BRS, Bi9!2024 ‘

AS GENERAL LIABIUTY

Ear COMMERGIAS, GENERAL LIABILITY
| CLAIMS: MADE [x occur

yore perton) | 35.006

AL BADVINJURY | $ 2.090.000
$2,020,000
G | $2,006,000

SENL AGGREGATE a APPLE

| ANY PROPRIETORPARTNERIENEGUTIVE [©

OFFIGERIMEMBER EXCLUNED? NIA ——

(Mandatory | in NH) CiBEASE - EA EMPLOYEE 3 __
5, dascnbe uv!

DESERT HON OF OPERATIONS below i EL CBEASE -POUCY LIMITS

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORG 101, Additional Ramarks Schodule, sf more space is required)

Regarding the Ganaral Liability cavacage, Waiver of Subrogation applies to the entities fisted betow per attached form CG 24 04 when required by writer
agreement.

Regarding the General Liability coverage, Blanket Additional Insured appties to the entities fisted below par atiached form GLS-180¢6 wnen required by written
agreement.

Regarding the General Liability coverage, Primary and Non-Contributory coverage applies to ine entities listed below per attached form CG 20 91 when
required by written agreement.

Additional insureds: Anthem Community Council inc: Anthem Parkside Community Asgeciation Inc.; Anthem Country Ciub Corsmunity Association Inc.;
Maricopa County, State of Arizona, Daisy Mountain Fire District; AAMLLC, their respective and affiliated entities and all of their respective directors, officers.
pariners, members, employees, and agents are hereby named as additianal insured. Insurance is primary and noncontributory. Display date is 07/03/2024

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 86086

AUTHORIZED REPRESENTATIVE

Drow ere

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

vem community park - Bing

https://www.bing.com/maps?q=anthem+community+park&pe-.,.

TAIEIMANNA Ore ae

Reyman Pyrotechniques/Any Pyro

Anthem 7/3/2024

Content of display

Following is the shell content of the display:
2 1/2 inch shells-70

3 inch shells-192

4. inch shells-160

5 inch shells-72

6 inch shells-24

ena INGE

MEMBER ID; 360241

RANDY L. .
REYMAN

REYMAN PYROTECHMICQUES Hil WN
NTCHITEY Cisse; AMO Tee TATA Pat

ae ed City of Flagetatt Fire Oepartment
| 7 217 W. Aspen Avenue
a Sal Plagetatl, AZ, 86001

Pyrotechnics Pornalt

Pormit Holder Randy Rayman

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| lssued By. de
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| pate lesuea: (7? 4

Daisy Mountain Fire Prevention

4WIS N Daisy Mountain Orive Anthem Az, 85086 623-465-7409 March 18, 2024

Mr. Reyman,

Thank you for the notice from Reyman Pyro-Techniques/Any Pyro stating you will be
conducting the fireworks display for the Anthem’s July 3rd, 2024 event and that you are
aware you will need to obtain a DMFD permit for this event. A valid County permit shall
be obtained and DMFD standby will be required on the day of the event. We look
forward to working with you again this year. Please let us know if you need any further
information.

Sincerely,

Dave Wichen

Dave Nielsen — Fire Marshal
Fire Prevention 623-465-7400