LESIURE WORLD APPLICATION._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, 
10th 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:
Name of Event:
Event Address:
Date and Time of Event:
DISPLAY DIRECTOR (permit will be issued to the following)
Name:
Phone:
Business:
Fax:
Address:
Email:
SUBMIT APPLICATION AND REQUIRED DOCUMENTATION TO:
Maricopa County Clerk of the Board of Supervisors 
 Email: ClerkBoard@mail.maricopa.gov
301 W. Jefferson Street, 10th Floor 
 
 Fax: 602-506-6402 
Phoenix, Arizona 85003 
For questions, please call the Clerk of the Board of Supervisors at: 602-506-3766.
RECEIVED 
9/27/2023
MARICOPA COUNTY CLERK 
BOARD OF SUPERVISORS
6:30 pm.
Leisure World Community
Community Event
908 S Power Rd. Mesa AZ 85206
Saturday, November 11, 2023
Cody Welty
Fireworks Productions of Arizona
17034 S 54th St. Chandler AZ 85226
480-423-5430

FIREWORKS DISPLAY SITE MAP
Indicate the following:
1.
North direction
2.
Distance from firing area to impact/fallout area
3.
Spectator location
4.
Storage area 
 
 
 
 
 
 
 
 
 
 
 
 
5.
Fire department access
6.
Hydrants
7.
Distance to structures
8.
Overhead lines
 
 
 
 
 
 
(North)

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

September 27, 2023 
 
Clerk of the Board of Supervisors 
Maricopa County  
301 W. Jefferson 10th Floor 
Phoenix, AZ. 85003 
 
To Whom It May Concern: 
 
Attached is the permit application for Leisure World Community event 
fireworks display scheduled for Saturday, November 11, 2023. Rural Metro 
Fire District will be the responding fire department and I’ve included an email 
response from them 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. 54th 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

CERTIFICATE HOLDER
© 1988-2010 ACORD CORPORATION.  All rights reserved.
ACORD 25 (2010/05)
AUTHORIZED REPRESENTATIVE
CANCELLATION
DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
LOC
JECT
PRO-
POLICY
GEN'L AGGREGATE LIMIT APPLIES PER:
OCCUR
CLAIMS-MADE
COMMERCIAL GENERAL LIABILITY
GENERAL LIABILITY
PREMISES (Ea occurrence)
$
DAMAGE TO RENTED
EACH OCCURRENCE
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
RETENTION
DED
CLAIMS-MADE
OCCUR
$
AGGREGATE
$
EACH OCCURRENCE
$
UMBRELLA LIAB
EXCESS LIAB
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES  (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
INSR
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
$
$
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
If yes, describe under
DESCRIPTION OF OPERATIONS below
(Mandatory in NH)
OFFICER/MEMBER EXCLUDED?
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
Y / N
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED
SCHEDULED
HIRED AUTOS
NON-OWNED
AUTOS
AUTOS
AUTOS
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
$
$
$
$
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
WVD
SUBR
N / A
$
$
(Ea accident)
(Per accident)
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).
The ACORD name and logo are registered marks of ACORD
COVERAGES
CERTIFICATE NUMBER:
REVISION NUMBER:
INSURED
PHONE
(A/C, No, Ext):
PRODUCER
ADDRESS:
E-MAIL
FAX
(A/C, No):
CONTACT
NAME:
NAIC #
INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Britton Gallagher
Everest Indemnity Insurance Co.
10851
Axis Specialty Ins Co
15610
FPA, Ltd.
17034 S 54th St
Chandler AZ 85226
Everest Denali Insurance Company
16044
AZ Assigned Risk Plan NCCI
702457345
A
X
1,000,000
500,000
X
1,000,000
2,000,000
2,000,000
SI8ML02344-231
10/9/2023
10/9/2024
X
Y
Y
C
1,000,000
X
X
X
SI8CA00258-231
10/9/2023
Y
Y
10/9/2024
B
X
4,000,000
4,000,000
P-001-000691697-02
10/9/2023
10/9/2024
X
Y
Y
D
6JUB-6R08411-5-23(AZ)
10/9/2023
10/9/2024
1,000,000
1,000,000
1,000,000
A
2nd Excess
9/26/2023
X
SI8EX01790-231
10/9/2023
10/9/2024
Each Occurrence
Aggregate
5,000,000
5,000,000
Additional Insured extension of coverage is provided by above referenced General Liability and Auto Liability polcies where required by written agreement.
Date of Display: November 11, 2023
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.
Leisure World Community Association
Finance Department
908 S. Power Road
Mesa AZ 85206

EXHIBIT A 
Designed for the Leisure World Community by:  Fireworks Productions of Arizona 
 
LEISURE WORLD COMMUNITY 
Mesa 
 
Saturday, November 11, 2023 
4 minute display 
1,200 Basin Effects 
 
 
This celebration contains a combination of fiery color and sparkling fireworks to thrill and 
electrify the competitors, attendees and their guests. 
 
 
 
4 Minute Aerial Basin Display: 
 
Your Aerial Basin Display will contain a total of 1,200 aerial basin effects  
(including numerous Basins using Red, White and Blue effects) 
                  
                  
1.5”  -    12  FPA Premier Multi-shot Specialty Basins 
 
(9 Multi-shot Basins fired one after another or together followed by 3 Multi-shot Basins fired 
simultaneously for the Grand Finale)

Pyrotechnician 
Certificate of Fitness 
 
Cody Welty 
 
R2300047 
 
Expiration Date: 05/04/2026 
 
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. 
 
 
John Mertens 
City of Phoenix Fire Marshal