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" TYPEOFWsuFJ`NCE I I PO CY NUGBER I P ICY EFF I POA�CY IXP I Louts ?. IGENEML UA&LITY CPI0050151 2/128017 EACH OCCURRENCE $1.000.000 ILO4%X.zFC1AGENEP_UABIUW I1/11f2018 - 5100000 IIX CLAMS-WDE IX OCCUR ME -DW onp ceewnI I S50M PERSONAL A ADVaLURY 151.000.000 -1 GGENERAL AGGREGATE 52,000,000 I GENLA R'v -.E U14n APPLIES PER: PRODUCTS - COMRCP AGG 152,000,000 I S IX 1 Past F-1 PVo Il Loc I AMOMO&LE UABafiY I IEp.II OMS Lc l 1 I ANY AUTO a001LY INNRY IPn>ys-.nl 15 �AO�'- I IAUi05 L -D I 1 tiR Cn TOS I_1 Nort 1NED ALT11 I I I ! I 9OOILY I.WURY IPerp9Cpr31I5 I IW. PPEPTY D:MAGE I S I5 J R BaE L Rue I' OCCUR 1 I EACH OCCURRENCE I S i AGGREGATE I S EXCESS UAP I (CWSLS-uADE I DED I I I S I I WORKERS COMPENSATWN ENSAn ON 11K STAIy IO:H-I AND ENPLOYERS'UA86fiY ;Y—/r111 ANTCEOWEML-F ARTNEPJEFECUME I E.L EACH ACGO'_'ri I5 I I OFFICE W?IEA1NMI E%CLUCiJ? Ln (wnap:vy H NMI NIAI I E.L. D:sEASE - EA EA'.r'LOYE6 s e.L D'SEASE-PGICY UWT I S Pn Ce.v tr.W-1 SCRI?rIQY OF OPERATIONS oahA I DFSCRIPTON OF OPERATIDNS/LOCAL S/ VENKLES(A:.arN ACORD 101, A 11Uw RpmwYs $clypWp,amplp 5P 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 °""" 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 LTR TYPE OF INSURANCE POULY NUICBER POLICY ELP I IIaVp POLICY IXP MMA i Ln'tas A ERUAY AL&uT CP10050151 2/12/2017 2/122016 I EACH OCCURRENCE 151,000.000 X COM.'AERCIALGENERAL UABPLITY I� CLAIHSNADE 1`I OCCUR AwI-IbT[EFIED 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 I i 1 is AIfrO1JOR1E lfARllfrY' ANY AUTD UL�NEC_ 1FU-F.Cs LEC I I i EeMQhYJ L LIAY 1 BODILYINVURY(Prr Aesm) 15 aDDILY INJURY(P. a N) 5 NON{Y.5NE0 F]REDAUi OS . AU.0S F-1 I I ! PROPEfliY DAAAGE I5 fepr m� I IS I I UHBREII A UAB 1 I OCCUR I-1 EXCESS UAB I 1 CtA1VS-MADE EACH OCCURRENCE is AGGREGA Is I I DEO 1 1 R -T N`nON 5 i Is 1 YIOMERS CONPEISATIONI TR I NCYiiTU I to=" AND EYPLOYERS'LUBaRT YJN 'NY PROPRLATOPUFARTNERIEXECU I., I El EACH ACCIDENT Is - OFFICERAAEMSER FXCLUDE"'� (113ndm M m NN) NIA. E.L. DISEASE - EA E VF-OYEEI 5 -vn. azacz CIFOPERAip DESCRIPTION CF ONS be:vx I IE.L DISEASE - POLICY LUAT I DESOMPnONDFOPERATIONS/LOCATIONS/VEHICLES (Amrh ACORD101.Addlolul R°r°a SUwdW..0.spl " /alum 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 .. _,€y ujN1,," Kingman High School 4182 Bank St. Baseball for fireworks p.7 Imagery O2016Dig 'ea'Globe- Map data O2016 Google 50h Q Shoot St'7'<