BROOKSEE ORGANIZATION_REDACTED (2)_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: Brooksee Organization
Name of Event: Mesa Marathon
Event Address: 3960 N Usery Pass Rd, Mesa 85207
Date and Time of Event: Saturday, February 4, 2023 @ approx. 6:30am

DISPLAY DIRECTOR (permit will be issued to the following)

Name: Ron Fuchs(please email or mail approval back to Cindy)

Business: Fireworks Productions of Arizona
Address: 17034 S 54th Street, Chandler AZ 85226

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

PONS
PND

(North)

8 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.

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

EXHIBIT A

MESA MARATHON

Full and Half
Saturday, February 4, 2023
MESA
MARATHON Total Aerial Effects

per Location 50
National Anthem:

“Rockets Red” 1 — 100mm Red Mine

1-8 shot x 3 sec. 30mm Red Crossette Plate

“Bombs Bursting” 1—5 Shot 30mm Cannonade Plate

End of Anthem: 1-8 shot x 15 sec. 30mm Red Crossette Plate
1- 100mm RWB Mine
1— 100mm Blue Mine

Marathon Start: 2 —8 shot x 6 sec. 30mm Asst. Comet Plates
2 — 100mm Glitter Crackle Mine
1 —8 shot x 6 sec. 30mm Cannonade Plate

NOTE: The Pyrotechnic effects listed above will be shot from 2 different
locations with a total of 50 effects per location.

Designed for the Mesa Marathon by: Fireworks Productions of Arizona

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ACCORD
—

CERTIFICATE OF LIABILITY INSURANCE

DATE (MMIDDIYYYY)
1/10/2023

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

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the

certificate holder in lieu of such endorsement(s).

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

policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to

PRODUCER

The Partners Group Ltd
11225 SE 6th St., Suite 110
Bellevue WA 98004

CONTACT
NAME:
PHONE
IC, No
E-MAIL
| ADDRESS:

Janet Nau

INSURER(S) AFFORDING COVERAGE

INSURER A : Everest Indemnity Insurance Co

INSURED 16021

FPA, LTD

Fireworks Productions of Arizona
17034 S. 54th Street

Chandler AZ 85226

INSURER B : Everest Denali Insurance Company

INSURER Cc : AXIS Surplus Lines Insurance Company

INSURER D: Travelers Property Casualty Co of America

INSURER E:

INSURER F :

COVERAGES CERTIFICATE NUMBER: 1219599317

REVISION NUMBER:

INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD

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.

OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

INSR [ADDL|SUBR] POLICY EFF | POLICY EXP
LIR TYPE OF INSURANCE INSR| WvD POLICY NUMBER {MM/DDIYYYY) | {MM/DDIYYYY) LIMITS
A | GENERAL LIABILITY Y $18ML02344221 4019/2022 1019/2023 | EACH OCCURRENCE $1,000,000
X DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $600,000
] CLAIMS-MADE MED EXP (Any one person) _| $/A
PERSONAL & ADVINJURY _| $ 1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
pouicy | X | SBS Loc $
COMBINED SINGLE LIMIT
B | AUTOMOBILE LIABILITY $18CA00258221 40/9/2022 1019/2023 | OO Nant $4,000,000
X | any AUTO BODILY INJURY (Per person) | $
ALLOWNED SCHEDULED i
|___} AUTOS [| AUTOS BODILY INJURY (Per accident) | $
X X | NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
c UMBRELLALIAB | X | occur P00100089169702 10/9/2022 10/9/2023 | EACH OCCURRENCE $4,000,000
X_| EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
DED | RETENTIONS $
D_ | WORKERS COMPENSATION 6R08414 10/9/2022 40192023 |X | WCSTATU- OTH
AND EMPLOYERS' LIABILITY TORY LIMIT! 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
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ 1,000,000
A_ | General Liability & SI8EX01790221 10/9/2022 10/9/2023 Each Occurrence $5,000,000
Auto Excess over $4M Aggregate $5,000,000

Named Insured, as required by written contract:
Date of Display: February 4, 2023

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 104, Additional Remarks Schedule, if more space is required)
The following are included as Additional Insured on General Liability as their interest may appear as respects operations performed by or on behalf of the

Location of Display: Usery Mountain Shooting Range 3960 North Usery Pass Road Mesa, AZ 85207
Additional Insured(s): State of Arizona; Arizona Game and Fish; Arizona Wildland Services; Rural Metro Fire Department; Mesa Marathon.

CERTIFICATE HOLDER

CANCELLATION

Brooksee, LLC

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.

2748S 671W
Pleasant Grove UT 84062

AUTHORIZED REPRESENTATIVE

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ACORD 25 (2010/05)

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

Mia Vargas (COB)

From: Cindy Herbel sy pcacaras
Sent: Tuesday, January 10, :

To: Clerk of the Board of Supervisors - COBX

Subject: FW: Fireworks - Feb 4 - Mesa Marathon - Usery Pass
Follow Up Flag: Follow up

Flag Status: Completed

Here you go. From Rural Metro. Is there anything else you see as missing?

Cindy Herbel

Pyro Adminisirative
Assistant

Fireworks
Productions
of Arizona

(office)
480-423-5430 (fax)
1-877-948-0090 (toll-free)
17034 S. 54th Street, Chandler, AZ 85226

From: Diamond, Kenneth

Sent: Tuesday, January 10, 2023 3:39 PM

To: Cindy Herbel

Subject: RE: Fireworks - Feb 4 - Mesa Marathon - Usery Pass

Hi Cindy
In reference to your fireworks shoot on February 4" 2023.
lam aware of your location at 3960 N Usery Pass Rd in Maricopa county and | do approve.

Thank you

Kenneth Diamond

Fire Captain

Fire Marshal

Rural Metro Fire Central Arizona

7631 E. Main St Mesa, AZ 85207
C: 480.869.2340

RURAL
‘METRO

FIRE DEPARTMENT

From: Cindy Herbel
Sent: Tuesday, January 10, 2023 3:29 PM

To: Diamond, Kenneth
Subject: EXT: Fireworks - Feb 4 - Mesa Marathon - Usery Pass

Importance: High

Mesa Marathon contacted us today to have a fireworks at their starting line for the Feb 4 full marathon site at Usery
Pass. | am applying with Maricopa County for a permit and just need a email stating that you are aware of the

display. Attached is the following:
e Rural Metro Notification letter

e Site Map
e Show Program
e COl

Please email me back that you are aware of this display and have no objections.

Thank you!

Cindy Herbel

Pyro Administrative
Assistant

Fireworks _
Productions qi!
of Arizona

a,

(fax)
1-877-948-0080 (toll-free)
17034 S. 54th Street, Chandler, AZ 85226