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FPYR2019-0008
ADDITIONAL SITES CHRONOLOGY CONTACTS NAME TYPE NAME ADDRESS1 CITY STATE ZIP PHONE FAX EMAIL APPLICANT FIREWORKS AMERICA POBOX 488 LAKESIDE CA 92040- 0488 office@fireworksameri ca.com BILL TO FIREWORKS AMERICA POBOX 488 LAKESIDE CA 92040- 0488 office@fireworksameri ca.com CHRONOLOGY TYPE STAFF NAME ACTION DATE COMPLETION DATE NOTES NOTE ARMANDO MAGALLON 10/24/2019 10/24/2019 APPLICANT APPLIED FOR INCORRECT PERMIT AND DID NOT UPLOAD DOCUMENTS. I RECEIVED DOCUMENTS YESTERDAY AND FINISHED CREATING AND TRANSFERING EVERYTHING OVER FROM THE INCORRECT PERMIT TO THIS ONE TODAY 10/24/2019. CONDITIONS Description: GOLF CLUB AT LQ / PUBLIC FIREWORKS DISPLAY / 11/16/19 Type: FIRE PYROTECHNICS Subtype: Status: FINALED Applied: 10/23/2019 AMA Parcel No: 764270041 Site Address: 60151 TRILOGY PKY PKY LA QUINTA,CA 92253 Approved: 10/25/2019 KHET Subdivision: TR 30023-1 Block: Lot: 136 Issued: 11/8/2019 ECON Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: 11/16/2019 KHET Valuation: $0.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: 90 - 2" MINE EFFECT 110 - 2.5" SINGLE BREAK AERIAL SHELLS 115 - 3" SINGLE BREAK AERIAL SHELLS 52 - 4" SINGLE BREAK AERIAL SHELLS 24 - 5" SINGLE BREAK AERIAL SHELLS 2 - 1.25" or smaller BOMBARDMENTS Printed: Tuesday, February 14, 2023 10:06:13 AM 1 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2019-0008 CONTACTS NAME TYPE NAME ADDRESS1 CITY STATE ZIP PHONE FAX EMAIL OWNER TLQ PARTNERS 1600 N LA HABRA HILLS DR LA HABRA CA 92253 FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT #CHECK #METHOD PAID BY CLTD BY Credit Card Fee 101-0000-43505 0 $7.52 $7.52 10/17/19 R55304 MOVED FROM FSEV2019- CREDIT KEVIN BRUECKNER AMA Credit Card Fee 101-0000-43505 0 $5.80 $5.80 11/8/19 WEB4294 CREDIT FIREWORKS AMERICA ECON Total Paid for Credit Card Fee: $13.32 $13.32 FIRE PYROTECHNICS 101-0000-42421 0 $242.00 $242.00 10/17/19 R55304 MOVED FROM FSEV2019- CREDIT KEVIN BRUECKNER AMA FIRE PYROTECHNICS 101-0000-42421 0 $80.00 $80.00 11/8/19 WEB4294 CREDIT FIREWORKS AMERICA ECON FIRE PYROTECHNICS PC 101-0000-42420 0 $161.00 $161.00 10/17/19 R55304 MOVED FROM FSEV2019- CREDIT KEVIN BRUECKNER AMA FIRE PYROTECHNICS PC 101-0000-42420 0 $242.00 $242.00 11/8/19 WEB4294 CREDIT FIREWORKS AMERICA ECON Total Paid for FIRE FEES: $725.00 $725.00 RECORDS MANAGEMENT FEE 101-0000-42416 0 $10.00 $10.00 10/17/19 R55304 MOVED FROM FSEV2019- CREDIT KEVIN BRUECKNER AMA Total Paid for RECORDS MANAGEMENT FEE: $10.00 $10.00 TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 $5.00 10/17/19 R55304 MOVED FROM FSEV2019- CREDIT KEVIN BRUECKNER AMA Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 $5.00 TOTALS:$753.32 $753.32 Printed: Tuesday, February 14, 2023 10:06:13 AM 2 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2019-0008 ATTACHMENTS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 10/24/2019 ARMANDO MAGALLON 1ST SUBMITTAL - APPLICATION AND SITE PLAN 11-15 Golf Club at La Quinta Permit App Signed.pdf 0 DOC 10/25/2019 KOHL HETRICK 11-15 Golf Club at La Quinta Permit APPROVED.pdf 11-15 Golf Club at La Quinta Permit APPROVED.pdf 1 DOC 11/18/2019 KOHL HETRICK FPYR2019-0008 FW CKLIST .pdf FPYR2019-0008 FW CKLIST .pdf 0 BOND INFORMATION INSPECTIONS SEQID INSPECTION TYPE INSPECTOR SCHEDULED DATE COMPLETED DATE RESULT REMARKS NOTES FIRE INSPECTOR KHET 11/16/2019 11/16/2019 APPROVED FSO - FSS K HETRICK REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED DATE STATUS REMARKS NOTES 1ST FIRE (1 WK)KOHL HETRICK 10/17/2019 10/24/2019 10/25/2019 APPROVED 1ST PERMIT TECH (1 DAY) ARMANDO MAGALLON 10/23/2019 10/24/2019 10/24/2019 COMPLETE PARENT PROJECTS Printed: Tuesday, February 14, 2023 10:06:13 AM 3 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2019-0008 Draft 5/1/2019 RIVERSIDE COUNTY FIRE DEPARTMENT FIREWORKS INSPECTION CHECKLIST Per State Fire Marshal Laws and Regulations for Transportation, Use and Storage of Fireworks in California Title 19 California Code of Regulations, Chapter 6 State Fireworks Regulations Location - Address Date Time Inspector Name Permit# Operator to initial items with area for initial once task has been completed. PAPERWORK Contact Pyro Operator before date of display to verify: o Arrival/Inspection Time o Set Safety Briefing/Staff Present o Determine Security or Site Contact (Cell Phone) o Discuss Weather Forecast o Discuss Possible Wind Triggers o Discuss Possible Test Shot (If Applicable) o Discuss Inspections of Mortars (Preloaded If Applicable and Requested by FS0) o Discuss for Approval to Fire Show Verify Approved Permit – attached [HSC, §12640] Approved Site Plan - attached Security Plan – attached Verify the local weather on the date of display PERSONNEL Verify and record pyrotechnic operator identification – Class & Number _____________________[Title 19, §997] Verify pyrotechnic operator possesses valid driver license of proper type - DL# _____________________ Verify and record pyrotechnic information on the identity and age of all assistants on application Safety Briefing & Staff Sign-in sheet (see last page of this form) SECURITY [Title 19, §992.6, §997] Verify site security of storage area, discharge area, display area and fallout area as indicated on approved plan. Verify arrangement for traffic and crowd control before, during and after display FIRE PROTECTION AND SAFETY EQUIPMENT Fire extinguishers (proper type and size) are available and accessible [Title 19, §1004(a)] Shovel and container available for retrieving duds [Title 19, §1004(a)] Verify with Pyrotechnic Operator appropriate protection gear, minimum a hard hat, eye protection, long sleeve shirt, gloves, long pants, and shoes or boots are available for persons discharging fireworks manually [Title 19, §1004(b)] MORTAR INSPECTION Trilogy Country Club 60151 Trilogy Pkwy, La Quinta 11/16/19 1900 hours FSS Kohl Hetrick FPYR2019-0008 4 4 4 4 4 4 4 4 4 4 4 4 4 Basic 3411-02 A5142267 Draft 5/1/2019 Compare list of mortar racks, etc. with actual equipment Mortars are approved for use with type of shells to be fired [Title 19, §999] Mortars are inspected prior to use for defects, debris, etc. [Title 19, §999] Base plugs are securely attached to bottom of mortars [Title 19, §999] Mortars are proper length for size of shells to be fired [Title 19, §999] RACK INSPECTION [Title 19, §1002(a) See Figure A] Racks have no more than 10 tubes per unit Base and ends of racks are nominal 2 inches thick lumber Racks have blocks (nominal 2”X4”) separating individual mortars Racks for mortars 3” or larger have side braces of 1” X 6” nominal lumber or ½”X4” p lywood All racks with more than 5 tubes have diagonal side braces Racks are secured to prevent falling over TROUGH INSPECTION [Title 19, §1002(b) See Figure B] No trough is more than 8 feet in length Bottom surface of trough is provided with ¾” plywood if not sufficiently stable to support firing of the mortar Troughs are constructed of minimum 3/4 “plywood and secured with 3/8” through-bolt, rods or angle iron “U” brackets at each end and center. Sand or soft dirt, free of racks or debris, is on-hand to fill trough Minimum separation distance between mortar is provided Trough is of adequate height to securely bury mortar 2/3 of their minimum legal length DRUM INSPECTION [Title 19, §1002(c) See Figure C] Drums are in good condition Sand or soft dirt, free of rocks or debris, is on-hand to fill drum Drums are of adequate size to provide minimum separation distance between mortars Drums are of adequate height to securely bury mortars 2/3 of their minimum legal length TRENCHES, ETC TO BURY MORTARS IN GROUND [Title 19, §1001] Planking below mortars is provided for unstable or unleveled surfaces Trenches are of sufficient depth to securely bury mortars 2/3 of their minimum legal length Minimum separation distance between mortars is provided Sand or soft dirt, free of rocks or debris, is on-hand to fill trench AERIAL SHELL INSPECTION [Title 19, §997, §1003] Number of shells matches quantity listed on permit – ask for Bill of Transportation Shells properly labeled for use in California ___ Operator examines shells for damage [req. operator initials once completed] ___ Operator verify size shell for proper fit in mortars [req. operator initials once completed] GROUND DEVICES INSPECTION [Title 19, §1003(e)] Ground devices match items listed on permit Location and spacing of devices is per approved permit Equipment available to secure & brace ground devices 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 MM MM Draft 5/1/2019 DISCHARGE FALLOUT AREA INSEPECTION Location is as per approved permit Minimum required fallout area is provided Arrangement provided to secure fall out area when shell loading begins ELECTRICALLY FIRED DISPLAY INSPECTION [Title 19, §992.1 – §992.4] Power source is restricted to batteries or individually isolated generators. Firing system Is protected against accidental firing Method for circuit testing is available Firing panel is located with continuously unobstructed full view of operator MANUALLY FIRED DISPLAY INSPECTION [Title 19, §1003(a)(3)] o Safety caps protecting fuses remain in place until immediately before firing RELOADING MORTARS DISPLAY INSPECTION o No HDPE mortars shall not be reloaded for a period of at least one (1) hour after use [Title 19, §999(d)] o Ready box(es) are located more than 25 feet upwind of the closest mortar o Ready box(es) are divided into separate compartments for each shell size o Ready box(es) are covered with a flame-resistive canvas cover OPERATION OF DISPLAY Discharge, display and fallout area are cleared of all unauthorized personnel prior to loading shells [Title 19, §997] No one under the age of 18 is in discharge, display and fallout area once loading of shells begins [Title 19, §997] Mortar are aimed to be within the fallout area and away from spectators [Title 19, §997] On electrically fired shows, discharge area is cleared of all people prior to electrical circuit testing [Title 19, §992.2 – 992.4] All devices are ONLY fired upon or signal from licensed operator [Title 19, §1003(d)] ___ During discharge of shells, operator observes activities to ensure wind and trajectory are adequate and makes adjustment if necessary [req. operator initials once completed] ___ If a misfire occurs, pyrotechnic shall handle in an appropriate manner [Title 19, §997, §1003(g)] [req. operator initials once completed] POST DISPLAY ACTIVITES NO ONE permitted to enter display, discharge or fall out area until pyrotechnic operator has determined the area to be safe and secure [Title 19, §1003(d)(3)] Entire firing area is inspected by pyrotechnic operator and crew to locate any unexploded shells. Shells located are properly disposed of [Title 19, §1003(f)(2)] Unfired shells: re-loaded and re-fire; removed and returned directly to supplier or stored in manner approved [Title 19, §1003(h)] Inspect surrounding area to verify that no fire(s) were started from debris 4 4 4 4 4 4 4 4 4 4 4 4 MM MM 4 4 4 4 Draft 5/1/2019 NOTIFICATION [Title 19, §1005] ➢ PYROTECHNIC OPERATOR will provide verbal report to State Fire Marshal for any incident involving injury or death to public or crew, or for any fire requiring emergency action or response resulting from the firing of the show ➢ PYROTECHNIC OPERATOR will provide a copy of all reports sent to the State Fire Marshal to Riverside County Fire Department – Office of the County Fire Marshal Draft 5/1/2019 Return this completed form to the office and place in file with original application and transportation permit. SAFETY BRIEFING AGENDA 1. Introduction of All Present 2. Review Required Safety Equipment/PPE 3. Communication Plan – Radio/Cell Phones 4. Plan for Securing Fallout Area 5. Review/Verify Weather Conditions 6. Emergency Response Procedure 7. Review Process for Approval to Fire Show Pyrotechnician Assistants Sign-In Print Name Signature ID/Driver’s License Pyro License Matthew Monge A5142267 3411-02 Andrew Lowe D5475081 NA Richard Bowers N6653441 NA James Bates B7376085 3671-02 David Wiskus A6705778 3689-02 Jordan Ball F2585215 NA Richelle Loranger D7014089 NA Alan Simsim F4543498 NA Nathan Javier F1920844 NA DESIGN & DEVELOPMENT DEPARTMENT 78-495 Calle Tampico La Quinta, California 92253 (760) 777-7125 FAX (760) 777-7011 o NEW o TENANT IMPROVEMENT PERMIT NO. PROJECT INFORMATION (Please Print) Project Name: Sign: Site Address: Print: City & Zip: •Pursuant to a Cooperative Agreement to Provide Fire Services, the Riverside County Fire Department serves as the City’s fire department, and the County designee serves as the City’s fire chief. Applicant recognizes this contracted arrangement and shall comply with County Fire Department directions. APPLICANT/CONTACT INFORMATION CONTRACTOR INFORMATION: o Same as Applicant info Applicant Name: Contractor #: Contact Person: Contact Person: Mailing Address: Mailing Address: City & Zip: City & Zip: Phone Number: Fax: Phone Number: Fax: Email: Email: o ------------ o $415 o $655 o $816 o $775 o $816 o $976 o $816 o $1216 o $415 o $335 o $415 o $335 o $175 o $495 o $575 o $335 o HOURLY @ $160/HR o $415 o $165 o $1056 o $655 o $575 o $415 o $415 o $1056 o HOURLY @ $160/HR o HOURLY @ $160/HR o HOURLY @ $160/HR o HOURLY @ $160/HR The Golf Club at La Quinta 60151 Trilogy Parkway Kevin T. Brueckner La Quinta, CA 92553 Fireworks America GPD528 Kevin Brueckner P. O. Box 488 Lakeside, CA 92040-0488 619-938-8277 619-938-8273 Riverside County Fire Department Office of the Fire Marshal Riverside Office: Palm Desert Office: 2300 Market Street, Ste. 150 77-933 Las Montañas Rd., Ste 201 Riverside, CA 92501 Palm Desert CA 92211 Phone: (951) 955-4777 ~ Fax: (951) 955-4886 Phone: (760) 863-8886 ~ Fax: (760) 863-7072 PLAN REVIEW FORM New Re-Submittal # As-builts FD Permit # County/City Permit# PROJECT INFORMATION Project Name: I have read and understand that Fire Dept. fees are Deposit Based Fees and there may be additional Address: money due prior to or after project final. Sign: City & Zip: Print: APPLICANT INFORMATION Company Name: Applicant Name: Address: Phone: City/ Zip: Email: BILLING INFORMATION: Same as applicant Company Name: Applicant Name: Address: Phone: City/ Zip: Email: The person listed on “Billing Information” will receive ALL billing, correspondence and refunds for any work billed to this permit. Any changes in billing information must be made in writing to our office. Plan Review Type (Check appropriate items) Form 1 – Revised 6/14/2017 Visit us at www.rvcfire.org Commercial Residential Other Office Use Only Plans Received Construction: Building Tenant Improvement (New/Existing) Cell Site High Pile/Racks HFA Systems: Sprinkler TI Sprinkler Sprinkler Monitoring Fire Alarm Hood & Duct Suppression Other Suppression Spray Booth UG Water Other: Storage Tanks: Dispensers Only Above Ground #_____ Underground #_____ Fee Paid: Date Paid: Check#: Received By: Receipt#(OCR) DBF Reviewed by: PC Review Date: Approved Denied Plans Stamped: Yes No Letter Attached: Yes No Job Card Included: Yes No DBF Called for Pick-Up Date: By: Picked-Up Date: By: Shipped By / Method DBF OFFICE USE ONLY Riverside County Fire Department ~ Office of the Fire Marshal Riverside Office (West): Palm Desert Office (East): 2300 Market Street, Ste. 150 77933 Las Montañas Road, Ste 201 Riverside, CA 92501 Palm Desert, CA 92211 Phone: (951) 955-4777 ~ Fax: (951) 955-4886 Phone: (760) 863-8886 ~ Fax: (760) 863-7072 PYROTECHNICS APPLICATION FD Permit # Assessor Parcel#(APN): I/we hereby make application for a permit to utilize pyrotechnic effects as defined by the California State Health & Safety Code, and agree to comply in every particular with the law pertaining thereto as set forth in Part 2 of Division II of the Health & Safety Code, and the rules and regulations adopted by the State Fire Marshal. EVENT INFORMATION Event Name: Event Contact: Address: Phone: City/ Zip: Type of Event: Event Date(s): Time Start: Time End: Total # of people: APPLICANT/SPONSORING ORGANIZATION INFORMATION Company Name: Applicant Name: Address: Phone: City/ Zip: Email: PYRO COMPANY INFORMATION Company Name: Public Display Lic. # Address: Phone: City/ Zip: Email: PYROTECHNIC OPERATOR INFORMATION Name of CA License Operator Supervising Display: __________________________________________________________ License Class: _____________________ License # ___________________________ 0. Form 21 – Revised 1/2/18 Visit us at www.rvcfire.org OFFICE USE ONLY Fee Paid: Date: Payment Method: Received By: Receipt# Permit for Transportation o Granted o Denied Signature: Title: Date: Person Assigned: Cell: Permit for Pyrotechnics o Granted o Denied Inspected by: Title: Date: Office Use Only Plans Received The Golf Club at La Quinta Thomas Brown 60151 Trilogy Way 760-771-0707 La Quinta, CA 92253 Private Party 11/16/2019 ~7:00 pm ~7:10 pm TBD Golf club (sponsor) /Fireworks America (applicant)Kevin Brueckner 60151 Trilogy Parkway La Quinta, CA 92253-7640 FA: 619-938-8277 office@fireworksamerica.com Fireworks America GPD-0528 PO Box 488 619-938-8277 Lakeside, CA 92040 office@fireworksamerica.com Matt Monge Basic Commercial 3411-02 PRODUCT INFORMATION Name of wholesaler supplying all devices to be used in display: Wholesale State License #: Name of importer/exporter supplying all devices to be used in display: Importer/exporter State License #: Devices or Effect Description (type & size) *Attach additional sheets if needed No. of Devices Approx. Burn Time Approx. Height Approx. Width Approx. Travel Distance Approx. Drop Approx. Diameter Mortar Type(s) Firing method: o Manual o Electric o Both Will reload/ refueling be necessary? o Yes o No Will it affect airport traffic? o Yes o No *If “yes”, pyrotech is responsible to notify FAA Ceiling Height (if indoors) Fall Out Zone (Distance in feet): LOAD SITE & STORAGE INFORMATION FOR DEVICES & EFFECTS Location of storage PRIOR to shipping to display site: Departure date from storage location: Storage Address & City: Route(s) being used: Location of storage DURING display: Describe provisions for return of unused/unfired product after display. Location of storage of unused/unfired product (if applicable). INSURANCE INFORMATION Policy number of Employee Compensation Insurance: Policy number of Public Liability Insurance: (attach copy) Fireworks America W-1132 Fireworks America I/E-1129 2" Mine Effects 2.5" Single Break Aerial Shells 110 2 secs 200' 100' 100' 10ft 2.5" 3" Single Break Aerial Shells 115 3 secs 250' 125' 100' 20 ft 3" HDPE 4" Single Break Aerial Shells 52 3.5 Secs 275' 135' 100' 25 ft 4" HDPE 5" Single Break Aerial Shells 24 4 secs 300' 150' 100' 30 ft 5" HDPE 1.25" or Smaller Bombardments 2 30 secs 175' 75' 75' 10 ft 1.25" X XX N/A Bunkers 01-15-19 12485 Hwy 67 N. Lakeside, CA 92040 Please see attached directions N/A; set-up upon arrival Returned to bunkers Bunkers at 12485 Hwy 67 N. Lakeside, CA 92040 CPP0104568069080254-2019 90 2 Secs 150ft 25'150' Ver 0ft 2"cardboard 350 ft Radius (700 ft Diameter) Application for Permit for a Public Display of Pyrotechnics P. O. Box 488 Lakeside, CA 92040-0488 (619) 938-8277 Fax (619) 938-8273 Bombardments - 2;Mines - 2 in - 90; Single Break Aerial Shells: 2.5 in - 110; 3 in - 115; 4 in - 52; 5 in - 24; Multi-Break Aerial Shells: Jenisser Valdez Riverside County Fire Dept. (CAL Fire) 77933 Las Montañas Road Ste 201 Palm Desert, CA 92211 The Golf Club at La Quinta Attn: Thomas Brown 60151 Trilogy Pkway La Quinta, CA 92253-7640 Fireworks & Stage FX America, Inc. on behalf of the Sponsor Listed Above requests a permit to conduct a public display of fireworks in accordance with Federal, State and Local Laws and Ordinances. 11/16/2019 7PM Site Information: Authority having Jurisdiction:Client: Date(s): Pyrotechnic Operator(s) and License Number: (where required) The Driving range at The Golf Club at La Quinta 60151 Trilogy Pkway La Quinta, CA 92253MatthewMonge 3411-02 (Operator Name) (License No.) and assistants. Proof of current General Liability Insurance and Workers Compensation Insurance is attached. A detailed diagram of the proposed firing site is attached. Ground Level Pyrotechnics (0 - 50 Foot typical Altitude): Low Level Pyrotechnics (51 - 125 foot typical altitude): Aerial Pyrotechnics (>125 foot typical altitude): 19261 PERMISSION TO CONDUCT A PUBLIC DISPLAY OF PYROTECHNICS AS SPECIFIED HEREIN IS HEREBY: PERMITTED DENIED Signature of Permitting Authority DateCircle Appropriate Title Description of Display: Time/Length:10 Min Office contact:Kevin Brueckner (619) 938-8277, Fax (619) 938-8273 Matthew Cell:714-381-0097 x 1 Email:cypresslights@gmail.com The Golf Club at La Quinta on 11/16/2019 in La Quinta, CA. Fireworks fired Electrically, by Computer, in Racks. 19261Fireworks & Stage FX Permit Reference No.Printed CERTIFICATE HOLDER © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECT PRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-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 $ $RETENTIONDED 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. 7KH 3DUWQHUV *URXS /WG 6( WK 6W 6XLWH %HOOHYXH :$ -DQHW 1DX MQDX#WSJUSFRP 7+( ,QVXUDQFH &RPSDQ\ )LUHZRUNV DQG 6WDJH ); $PHULFD ,QF)LUHZRUNV DQG 6WDJH ); $PHULFD //&32 %R[ /DNHVLGH &$ $ ; ; &33 ; < ([FOXGHG $ ; ;; ;&RPS ;&ROO &33 $; (/3 ; */ 2QO\ $$([FHVV /LDE a $XWR+LUHG $XWR 3K\V 'PJ/LPLW 75. 7UO (/3 &33 (DFK 2FFXUUHQFH$JJUHJDWH ([FHVV /LDELOLW\ a */ 0 ;6 0 a 3ROLF\ (/3 a 7+( ,QVXUDQFH &RPSDQ\ a (IIHFWLYH WR 7KH IROORZLQJ DUH $GGLWLRQDO ,QVXUHG RQ *HQHUDO /LDELOLW\ DV WKHLU LQWHUHVW PD\ DSSHDU DV UHVSHFWV WR RSHUDWLRQV SHUIRUPHG E\ RU RQ EHKDOI RI WKH 1DPHG,QVXUHG DV UHTXLUHG E\ ZULWWHQ FRQWUDFW 6KRZ GDWH 6KRZ ORFDWLRQ 7KH *ROI &OXE DW /D 4XLQWD 7KH *ROI &OXE DW /D 4XLQWD &LW\ RI /D 4XLQWD 7KH &RXQW\ RI 5LYHUVLGH LWV RIILFHUV DJHQWV HPSOR\HHV DQG VHUYDQWV ZKHQ DFWLQJ LQ WKHLU RIILFLDO FDSDFLW\ DVVXFK 7KH GXO\ OLFHQVHG S\URWHFKQLF RSHUDWRU UHTXLUHG E\ ODZ WR VXSHUYLVH DQG GLVFKDUJH WKH SXEOLF GLVSOD\ DFWLQJ HLWKHU DV DQ HPSOR\HH RI WKH LQVXUHG RU DV DQLQGHSHQGHQW FRQWUDFWRU DQG WKH 6WDWH RI &DOLIRUQLD LWV RIILFHUV DJHQWV HPSOR\HHV DQG VHUYDQWV DUH LQFOXGHG DV DGGLWLRQDO LQVXUHGV SHU ZULWWHQ FRQWUDFW 7KH *ROI &OXE DW /D 4XLQWD 7ULORJ\ 3NZ\/D 4XLQWD &$ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 05/30/2019 Whiteboard Risk & Insurance Solutions, LLC 3665 Ruffin Rd. #307 San Diego CA 92123 John Tillery (858) 223-1170 (858) 223-1170 solutions@whiteboardrisk.com P.O. Box 488 Lakeside CA 92040 State Compensation Insurance Fund 35076 A Y 9080254-2019 6/1/2019 6/1/2020 1,000,000 1,000,000 1,000,000 A Workers Compensation L&H-904878-2019 06/01/2019 06/01/2020 Each Accident 1,000,000 Disease Ea EE 1,000,000 Disease Pol Lim 1,000,000 Fireworks & Stage FX America, LLC Proof of Insurance. Proof of Insurance