BOULDER CREEK HIGH SCHOOL 10.06.23 REDACTED.PDF

RECEIVED

MARICOPA COUNTY BOARD OF SUPERVISORS AUG. 03-2023

301 West Jefferson Street, 10th Floor, Phoenix, Arizona 85003
MARICOPA COUNTY

APPLICATION FOR FIREWORKS DISPLAY CLERK BOARD OF suPERvisoRS:

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,
40" 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: Boulder Creek High School

Name of Event: Football Game Fireworks Senior Night

Event Address: 40404 N Gavilan Peak Parkway, Anthem AZ 85086

Date and Time of Event: Friday, October 6, 2023 @ approx. 6:45p-9:30pm

DISPLAY DIRECTOR (permit will be issued to the following)
Kendon Victor (please email or mail approval back to Cindy)

Name:

hm |
|

Business: Fireworks Productions of Arizona
Address: 47034 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:

Fire department access
Hydrants

Distance to structures
Overhead lines

1. North direction

2. Distance from firing area to impact/fallout area
3. Spectator location

4. Storage area

Do oer

(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

a) ® DATE (MM/DDIYYYY)
ACORD) CERTIFICATE OF LIABILITY INSURANCE eemnon

THIS CERTIFICATE 1S 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 GONTACT Janet Nau
Bellevue WA 98004 ABUHEss: jnau@tpgrp.com
INSURER(S) AFFORDING COVERAGE 7 NAIC #

INSURER A: Everest Indemnity Insurance Co 10851
INSURED 16021) insurer B ; Everest Denali Insurance Company 16044
EPA LID Productions of Arizona INsuRER c: AXIS Surplus Lines Insurance Company 26620
17034 S. 54th Street INSURER D: Travelers Property Casualty Co of America 25674
Chandler AZ 85226 INSURER E:

INSURER F :
COVERAGES CERTIFICATE NUMBER: 1238783513 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
LTR TYPE OF INSURANCE SR| WD. POLICY NUMBER (MMIDD! (MMIDDIVYYY) LIMITS
A | GENERAL LIABILITY Y $18ML02344221 40/9/2022 10/9/2023 | EACH OCCURRENCE $ 4,000,000
ina DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $ 500,000
‘| CLAIMS-MADE, MED EXP (Anyone person) _| $/A
PERSONAL & ADV INJURY _| $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000
pouicy | X | FRO: Loc s
COMBINED SINGLE LIMIT
B | AUTOMOBILE LIABILITY $18CA00258221 10/9/2022 1019/2023 | COMBINED § $4,000,000
X | any AUTO BODILY INJURY (Per person) | $
ALL OWNED SCHEDULED ;
ALL OW [| SCHED BODILY INJURY (Per accident) | $
x NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
c UMBRELLALIAB | X | occur P00100089169702 40/9/2022 10/9/2023 | EACH OCCURRENCE $ 4,000,000
X | EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000
pep |__| Retentions $
D | WORKERS COMPENSATION 6RO8414 40/9/2022 40/9/2023 |X | .WOSTATU- OTH-
AND EMPLOYERS’ LIABILITY YIN ORY LIME a
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
DESGRIPTION OF OPERATIONS below E.L, DISEASE - POLICY LIMIT | $ 1,000,000
A | General Liabllity & ‘SI8EX01790224 40/9/2022 10/9/2023 | Each Occurrence $5,000,000
Auto Excess over $4M Aggregate $5,000,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, 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
Named Insured per form #ECG 20592 0509 Additional Insured-Designated Person or organization attached:

Date of Display: October 6, 2023

Location of Display: Boulder Creek High School, 40404 N Gavilan Peak Parkway, Anthem AZ 85086

Additional Insured(s) :State of Arizona; Maricopa County; Daisy Mountain Fire District; Deer Valley Unified School District #97; Boulder Creek High School;
Boulder Creek Football Foundation.

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.

Deer Valley Unified Schoo! District #97

18424 N. 51st Avenue

Glendale AZ 85308 AUTHORIZED REPRESENTATIVE

er lal

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

POLICY NUMBER:  SI8ML02344221

COMMERCIAL GENERAL LIABILITY
ECG 20 592 05 09

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED — DESIGNATED
PERSON OR ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s)

ANY PERSON OR LEGAL ENTITY IN WHICH YOU HAVE A WRITTEN CONTRACT, AGREEMENT, OR
PERMIT WHICH REQUIRES THAT YOU NAME THE CONTRACTING PARTY AS AN ADDITIONAL INSURED.

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section Il — Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", “property
damage" or "personal and advertising injury" but
only to the extent caused, in whole or in part, by
your acts or omissions or the acts or omissions of
those acting on your behalf:

4. In the performance of your ongoing operations;
or

2. In connection with your premises owned by or
rented to you.

B. The insurance afforded to an additional insured
shall only include the insurance required by the
terms of the written agreement and shall not be
broader than the coverage provided within the
terms of the Coverage Part.

ECG 20 592 05 09

Copyright, Everest Reinsurance Company 2009

C. The Limits of Insurance afforded to an additional
insured shall be the lesser of the following:

4. The Limits of Insurance required by the written
agreement between the parties; or

2. The Limits of Insurance provided by this Cov-
erage Part.

D. With respect to the insurance afforded to an addi-

tional insured, the following additional exclusion
applies:
This insurance does not apply to “bodily injury’,
“property damage" or "personal and advertising in-
jury" arising out of any act or omission of an addi-
tional insured or any of its employees.

Page 1 of 1

Includes copyrighted material of Insurance Services Office, Inc., used
with its permission.

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EXHIBIT A

BOULDER CREEK HIGH SCHOOL
Anthem

Friday, October 6, 2023

Senior Night
Total Aerial Effects 58

Boulder Creek High School’s Senior Celebration will contain a multitude of fantastic
shells in beautiful colors to celebrate this year’s Seniors.

Aerial Display:
A large assortment of brilliantly-colored shells, including Chrysanthemums, Crowns,

Peonies and Diadems in gorgeous Reds, Yellows, Blues, Greens, Silvers, and Golds.

Your Aerial Display will contain a total of 58 aerial shells shot during important moments of
the evening to excite the home crowd and celebrate the Jaguars’ accomplishments.
2.5” - 58 Chinese Fancy’s & Specials
Boulder Creek High School's show to consist of:
TEAM INTRO: 7 —2.5” Aerial Shells
NATIONAL ANTHEM: 7 - 2.5” Aerial Shells at the end
SCORE SHELLS: 3 - 2.5” Aerial Shells each Touchdown or Field Goal (30 Total)

TEAM INTRO AT END OF HALF-TIME: 7 - 2.5” Aerial Shells

END OF GAME: 7 - 2.5” Aerial Shells
(Any remaining Score Shells shot at end of game)

Designed tor Boulder Creek High School by: Fireworks Productions of Arizona

(- City of Phoenix

Fire Department

FIRE PERMIT

150 South 12th Street

To find out about Phoenix construction code adoption

news and to research your permits or projects, please Phoenix, Arizona 85034 POST THIS PERMIT ON JOB SITE
visit htp:thasw phone goviPOD General Information (602)262-6771
Permit # F702 2203504 || Issue Date 19-APR-2022 Expires 18-APR-2025
Permit Description DAVE M. POLLOCK
Project 01-1559 150 S 12TH ST -
| Address NOT FOUND Zoning |
Description/Scope of Work: FIREWORKS/PYRO NEW CERT OF FITNESS CARD

PERMIT TO CONDUCT FIREWORKS SHOWS IN THE CITY OF PHOENIX:

OUTDOORITHEATRICAL FIREWORKS CARD HOLDER:
Dave Pollock

EMPLOYED BY:

Fireworks Productions of Arizona
17034 S. 54 Street

Chandler, AZ 85226

480-948-0090 / lori@fireworksaz.com

THIS PERMIT IS NOT TRANSFERABLE

COPY RECEIVED BY DATE
ISSUED BY DATE
Valuation: $0

Owner Information Certificate of
—_——_a———=—— ertificate 0
Name Occupancy Type: COFC
Address

Contractor Information Type Contact Phone
Name FIREWORKS PRODUCTION OF ARIZO! Ins Exp

Address 17034 S 54TH ST City/St/Zip CHANDLER AZ 85226 Phone 480-948-0090

Permit Issued By APA Entered By APA

Instructions and Comments

Inspections Required: FIRE-GEN : |

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