HomeMy WebLinkAbout05/15/2017 Item 007 Apr 26 1710:28a p.1
APPLICATION FOR FIREWORKS DISPLAY
APPLICATION is hereby made for the granting of a permit to conduct a supervised fireworks display.
Date of Event '_0Z 3—_ / 7
Location: 0 82 11/, 84,vk sr Ji-IAl�'/'s7A 4 a4/eft
Applicant: _- _ :;,•,41/..1- SS
Company: Xou,c2'' /g & �S
oz Lilt/q
Address: /6 92— AZ /Perth( 81174 c5*-( ' . c 6. Lit 4-2 840.3
Telephone: 9J— 704 -acre _ _Applicant will be in charge of this display and responsible for the acts performed thereby; and states that
he is a qualified and competent person to direct this display in such manner that it will not be hazardous to
property or endanger any person.
(Director of Display)
APPROVAL OF FIREWORKS DISPLAY BY. FIRE CHIEF
I have investigated the premises and proposed handling of the display described by the applicant and
found the premises and proposed handling of the display to be satisfactory and found the applicant to be a
competent operator.
(See alIciehect iQi t✓
(Signature)
APPROVAL BY PERS IN CHARGE OF PREMISES
• /—e/ (Signature) .
1
t FIREWORKS DISPLAY PERMIT
The application having been filed with the undersigned pursuant to Section 36-1603, A.R.S., 1956,
together with proper bond as provided by laws and same having been approved by the Fire Chief:
Permission is hereby granted to conduct a fireworks display.
In the event of postponement of said show, said display to be given not later than one week from date
syca.ified above.
Bond Approved: Mo - oun . 't+�sors Approved:
�- Ii
Mo County Risk Management Cha rm•+ :.ard of Supe isors
5/01 / 7 5ls at
Date Date
7
Apr.27.2017 02:10 PM NACFD 9287575316
Apr 261710:31 a p,1
APPLICATION FOR FIREWORKS DISPLAY
APPLICATION* is hereby made for the granting of a permit to conduct a supervised fireworks display.
Date of Event:
Location:
Applicant:
–173— /
a> .4 ✓.1- 44At.SS
PAGE. 2/ 2
Company: ��Ou�lD £ f /R�LJORtJGs
Address: /6 5%2— '5# &;6. *4 S.V., 5
Telephone: _ 9.24'– %Ols —S-B:Sd
Applicant will he in charge of this display and responsible for the acts performed thereby; and states that
he is a qualified and competent person to direct this display in such manner that it will not be hazardous to
property or endanger any person.
(Director of
APPROVAL OF FIREWORKS DISPLAY BY FIRE CIIIEF
I have investigated the premises and proposed handling of the display described by the applicant and
found the premises and proposed handling of the display to be satisfactory and found the applicant to be a
competent operator.
(5ignat O
APPROVAL BY PERSON IN CHARGE OF PREMSES
(Signature)
FIREWORKS DISPLAY PERMIT
The application having been filed with the undersigned pursuant to Section 36-1603, A.R.S., 1956,
together with proper bond as provided by laws and same having been approved by the Fire Chief:
Permission is hereby granted to conduct a fireworks display.
In the event of postponement of said show, said display to. be given not later than one week from date
specified above.
Bond Approved: Mohavc County Board of Supervisors Approved_
Mohave County Risk Management
Date
Chairman – Board of Supcnisors
Apr 26 17 11:16a
POLICYNUMBER: CPI0050151
p.3
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided unde the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s)
1
I Location(s) Of Covered Operations
Ychave Ccunty
Any and all
700 W. Beale St
DO Box. 7000
F1.noman, AZ 86402
�Addic Coral Prern:um is $100 P01iy Rarned.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section 11 - Who Is An Insured is amended to in-
clude as an additional insured the person(s) or or-
ganization(s) shown in the Schedule, but only with
respect to liability for "bodily injury". 'property dam-
age" or "personal and advertising injury' caused, in
—whole or -in -part, -by=------— --
1. Your acts or omissions; or
2. The acts or omssions of those acting on your
behalf;
in the performance of your ongoing operations for
the additional insured(s) at the location(s) desig-
nated above.
However:
1. The insurance afforded to such additional in-
sured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured
is required by a contract or agreement. the in-
surance afforded to such additional insured
will not be broader than that which you are re-
quired by the contract or agreement to provide
for such additional insured.
B. With respect to the insurance afforded to these
additional insureds, the following additional exclu-
sions apply:
This insurance does not apply to bodily injury" or
"property damage" occurring after:
1. All work, including materials, parts or equip-
ment furnished in connection with such work,
on the project (other than service. mainte.
nance or repairs) to be performed by or on
behalf of the additional insured(s) at the loca-
tion of the covered operations has been com-
pleted: or
2. That portion of your word out of which the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or subcontractor
engaged in performing operations for a princi-
pal as a part of the same project.
CG 20 10 04 13 Copyright, Insurance Services Office, Inc., 2012 Page 1 of 2
i\SURED C920,00413.:nc
Apr 2617 11:17a
POLICYNUMBER: CPI0050:5i
p.4
COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/ COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Jame Of Person Or Organization:
7onave County
%00 W. Seale st
10 Pox 7000, Kingman, AZ 86402
Addit°onai P -ami um is S150 =rally °arned
nformation required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV - Conditions:
We waive any right of recovery we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work' done under a contract with that person or
organization and included in the "products -completed
operations hazard'. This waiver applies only to the
person or organization shown in the Schedule above.
CG 24 04 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 1
?EisU33D cg25 oaa . tac
Apr 261711:17a
p.5
CERTIFICATE OF LIABILITY INSURANCE I An.,
THIS CERTIFICATE IS ISSUED AS A Pd ATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EMEND 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: It the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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 cortificate does not confer rights to the
PRODUCER
Ryder Rosacker McCue & Huston (MGD by Hull & Compa
509 W Koenig St
3rand Island NE 68802
INSURED
Round Eyes Fireworks
Round Eyes LLC
1642 McCulloch Blvd. N. Ste. 326
Lake Havasu City AZ 86403
COVERAGES CERTIFICATE NUMBER: 2032204415 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. NOfWTHSIANDING 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 SHOIAN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
L"
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POA�CY IXP
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IGENEML UA&LITY
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2/128017
EACH OCCURRENCE $1.000.000
ILO4%X.zFC1AGENEP_UABIUW
I1/11f2018
- 5100000
IIX
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PERSONAL A ADVaLURY 151.000.000
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AGGREGATE 52,000,000
I GENLA R'v -.E U14n APPLIES PER:
PRODUCTS - COMRCP AGG 152,000,000
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Blanket Additional Insured applies to the entities listed below per attached form GLI -150s when required by written agreement
Additional Insured per GLI -150s Kingman High School; Kingman Unified School Dist,
Additional Insured Per CG2010 including WOS: Mohave County
Location of display: 4182 N. Bank Street, Kingman, AZ 86409
Date of diplay: 051232017
CERTIFICATE HOLDER CANCELLATION
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Mohave County
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 7000
ACCORDANCE WITH THE POLICY PROVISIONS.
Kingman AZ 86402
AUrNORQZD REPRESEMATIVE
I
U
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
Apr 26 17 11:17a
E.
ACOROCERTIFICATE OF LIABILITY INSURANCE
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CERTIFICATE :MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
4262017
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: H the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed, If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, Certain policies may require an endorsement. A statement an this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER
Ryder Rosacker McCue & Huston (MGD by Hull 8 Compa
509 W KoenigSt
Grand Island E 68802
CON NAME. Knc Wolfe
PHONE FAX
- - 1 1u, -.130E -387-710q
7-7
q-Mu� .I Molfe on�yderinsuranne.corn
WSURER 5 AFFORDDIG COVERAGE I NAIC J
i Ln'tas
MURER A' eLE IND
ERUAY
AL&uT
INSURED
INSURER 9:
Round Eyes Fireworks
Round Eyes LLC
1642 McCulloch Blvd. N. Ste. 326
INSURER C:
NSUo. I
=1.1
INSURER E:
Lake Havasu City AZ 86403
INSURER F: 1
COVERAGES CERTIFICATE NUMBER: 1311770239 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELO`N HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REOUIREM'c NT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO VNIICH 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 SHOV&I MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSRI
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TYPE OF INSURANCE
POULY NUICBER
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AL&uT
CP10050151
2/12/2017
2/122016
I EACH OCCURRENCE 151,000.000
X COM.'AERCIALGENERAL UABPLITY
I� CLAIHSNADE 1`I OCCUR
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PREMISES IEa ammznal 15100.1X1()
MED EXP An one P.Wool 1 55.0011
PERSONA S AW.NJURY 151000.000
GENERAL AGGREGATE If2,000.000
"=NLAGGREGATEU. APFUes PER:
(� RCUCY 1� PRO- 1F] LOC
PRnNU`6- CONPJOPAGGIS2.000.000
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Blanket Additional Insured applies to the entities listed below per attached form GLI-15Gs when required by written agreement.
Additional Insured per GLI -150s: Kingman High School: Kingman Unified School Dist.
Additional Insured Per CG2010 including WOS: Mohave County
Location of display: 4182 N. Bank Street, Kingman, AZ 86409
Date of display: 0523/2017
Kingman High School
4182 N. Bank St.
Kingman AZ 86405
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS
AUTNORUED REPRESENTATIVE
P
® 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 2S (2010/13S) The ACORD name and logo are registered marks of ACORD
Apr 26 17 11:18a
3'42016 I nqg High School -Google Maps
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4182 Bank St. Baseball for fireworks
p.7
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