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FPYR2020-0003ADDITIONAL SITES CHRONOLOGY CONTACTS NAME TYPE NAME ADDRESS1 CITY STATE ZIP PHONE FAX EMAIL APPLICANT ANDALUSIA COUNTRY CLUB 58588 MADISON CLUB LA QUINTA CA 92253 JCUMMINGS@ANDALU SIACC.COM BILL TO GARDEN STATE FIREWORKS 8055 SPEEDWAY BLVD STE E 103 LAS VEGAS NV 89115 SJPYRO@SBCGLOBAL.N ET CONDITION TYPE CONTACT DATE ADDED DATE REQUIRED DATE SATISFIED STATUS REMARKS NOTES READY TO ISSUE CHECKLIST ARMANDO MAGALLON 10/22/2020 10/23/2020 COMPLETE FEES DUE FEES DUE CHRONOLOGY TYPE STAFF NAME ACTION DATE COMPLETION DATE NOTES NOTE KAYLI ALFORD 10/23/2020 10/23/2020 OK TO ISSUE PER KOHL. FEES PAID. CONDITIONS Description: ANDALUSIA / 11/07/2020 / 8:45PM / FIREWORKS Type: FIRE PYROTECHNICS (WEB)Subtype: Status: FINALED Applied: 10/22/2020 AMA Parcel No: 764200068 Site Address: 59195 MARBELLA LA QUINTA,CA 92253 Approved: 10/22/2020 KHET Subdivision: Block: Lot: Issued: Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: 11/7/2020 KHET Valuation: $0.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: Printed: Thursday, February 16, 2023 12:48:20 PM 1 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2020-0003 CONTACTS NAME TYPE NAME ADDRESS1 CITY STATE ZIP PHONE FAX EMAIL CONTRACTOR GARDEN STATE FIREWORKS 8055 SPEEDWAY BLVD STE E 103 LAS VEGAS NV 89115 SJPYRO@SBCGLOBAL.N ET OWNER CORAL OPTION I 81570 CARBONERAS LA QUINTA CA 0 INSPECTIONS SEQID INSPECTION TYPE INSPECTOR SCHEDULED DATE COMPLETED DATE RESULT REMARKS NOTES FIRE FINAL**KHET 11/7/2020 11/7/2020 APPROVED FSO STANDBY REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED DATE STATUS REMARKS NOTES PARENT PROJECTS FINANCIAL INFORMATION DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT #CHECK #METHOD PAID BY CLTD BY FIRE PYROTECHNICS 101-0000-42421 0 $322.00 $322.00 10/23/20 R62834 005428 CHECK ANDALUSIA COUNTRY CLUB AHI FIRE PYROTECHNICS PC 101-0000-42420 0 $403.00 $403.00 10/23/20 R62834 005428 CHECK ANDALUSIA COUNTRY CLUB AHI Total Paid for FIRE FEES: $725.00 $725.00 RECORDS MANAGEMENT FEE 101-0000-42416 0 $10.00 $10.00 10/23/20 R62834 005428 CHECK ANDALUSIA COUNTRY CLUB AHI Total Paid for RECORDS MANAGEMENT FEE: $10.00 $10.00 TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 $5.00 10/23/20 R62834 005428 CHECK ANDALUSIA COUNTRY CLUB AHI Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 $5.00 TOTALS:$740.00 $740.00 Printed: Thursday, February 16, 2023 12:48:20 PM 2 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2020-0003 ATTACHMENTS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 10/22/2020 ARMANDO MAGALLON APPLICATION andalusia plot 2020.pdf 0 DOC 10/26/2020 KOHL HETRICK FPYR2020-0003 - PUB DISPLAY PERMIT - APPROVED.pdf FPYR2020-0003 - PUB DISPLAY PERMIT - APPROVED.pdf 1 DOC 11/8/2020 KOHL HETRICK FPYR2020-0003 - FW CHECKLIST.pdf FPYR2020-0003 - FW CHECKLIST.pdf 1 BOND INFORMATION 1ST PERMIT TECH (1 DAY) ARMANDO MAGALLON 10/22/2020 10/23/2020 10/27/2020 COMPLETE 1ST FIRE - ETRAKIT (1 WK) KOHL HETRICK 10/22/2020 10/29/2020 10/22/2020 APPROVED SEE ATTACHMENTS Printed: Thursday, February 16, 2023 12:48:20 PM 3 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2020-0003 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 PHONE: (205) 854-5806 EMAIL: dib@draytonins.com FAX: (205) 854-5899 C E R T I F I C A T E O F I N S U R A N C E NO. 014316 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000016477-09 NAMED INSURED Garden State Fireworks, Inc. New Vernon Fireworks P.O. Box 403 Millington, NJ 07946 POLICY TERM March 1, 2020 to March 1, 2021; Both Days 12:01 A.M. Standard Time COVERAGE Commercial General Liability: Occurrence Basis Claims Made Basis LIMIT OF LIABILITY $5,000,000 each occurrence, $10,000,000 general aggregate, $6,000,000 products/completed operations aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS Public fireworks display and special effects contractor It is certified that, if named below, this policy includes as Additional Insureds 1) the sponsor(s), promoter(s), organizer(s) (including other entities having similar interests), of insured pyrotechnic events and/or 2) the owner(s) of real property (or barges) at which insured pyrotechnic events are held and/or 3) the owner(s), manager(s), tenant(s), mortgagee(s) (including other entities having similar interests), of buildings, stadiums, arenas and similar facilities at which insured pyrotechnic events are held and/or 4) the licensing or permitting authority, or other authority having jurisdiction, issuing licenses/permits for insured pyrotechnic events and/or 5) any other entity for which the insurance is required to be afforded under written contract. Coverage applies only as respects the legal liability of such Additional Insured(s) for bodily injury and property damage caused by the operations of the Named Insured. The insurance afforded any Additional Insured excludes liability for bodily injury or property damage arising from the Additional Insureds own negligent acts or omissions or from the failure of such Additional Insured to fulfill its obligations specified in its contract with the Named Insured. NAME(S) OF ADDITIONAL INSURED(S) Sunrise LQ LLC, Andalusia Country Club LLC, Riverside County Fire Department, CAL Fire, All subsidiaries and their respective agents, officers, members, directors, employees, successors and assigns, as additional insureds. DISPLAY LOCATION DISPLAY DATE(S) Andalusia Country Club 11/7/2020 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. 10/7/2020 DATE OF ISSUE A.J. STRINGER, PRESIDENT 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 11270-02 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 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 Troughs - 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 SJ SJ 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 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 Pyro License Signature 11-07-2020 11-07-2020 11-07-2020 11-07-2020 DRAYTON INSURANCE BROKERS, INC. 2500 CENTER POINT ROAD, SUITE 301 POST OFFICE BOX 94067 BIRMINGHAM, ALABAMA 35215 BIRMINGHAM, ALABAMA 35220 PHONE: (205) 854-5806 EMAIL: dib@draytonins.com FAX: (205) 854-5899 C E R T I F I C A T E O F I N S U R A N C E NO. 014316 We certify that insurance is afforded as stated below. This Certificate does not affirmatively or negatively amend, extend or alter the coverage afforded by the insurance policy and the insurance afforded is subject to all the terms, exclusions and conditions of the policy. INSURER Admiral Insurance Company POLICY NO. CA000016477-09 NAMED INSURED Garden State Fireworks, Inc. New Vernon Fireworks P.O. Box 403 Millington, NJ 07946 POLICY TERM March 1, 2020 to March 1, 2021; Both Days 12:01 A.M. Standard Time COVERAGE Commercial General Liability: Occurrence Basis Claims Made Basis LIMIT OF LIABILITY $5,000,000 each occurrence, $10,000,000 general aggregate, $6,000,000 products/completed operations aggregate The limit of liability shall not be increased by the inclusion of more than one insured or additional insured. INSURED OPERATIONS Public fireworks display and special effects contractor It is certified that, if named below, this policy includes as Additional Insureds 1) the sponsor(s), promoter(s), organizer(s) (including other entities having similar interests), of insured pyrotechnic events and/or 2) the owner(s) of real property (or barges) at which insured pyrotechnic events are held and/or 3) the owner(s), manager(s), tenant(s), mortgagee(s) (including other entities having similar interests), of buildings, stadiums, arenas and similar facilities at which insured pyrotechnic events are held and/or 4) the licensing or permitting authority, or other authority having jurisdiction, issuing licenses/permits for insured pyrotechnic events and/or 5) any other entity for which the insurance is required to be afforded under written contract. Coverage applies only as respects the legal liability of such Additional Insured(s) for bodily injury and property damage caused by the operations of the Named Insured. The insurance afforded any Additional Insured excludes liability for bodily injury or property damage arising from the Additional Insureds own negligent acts or omissions or from the failure of such Additional Insured to fulfill its obligations specified in its contract with the Named Insured. NAME(S) OF ADDITIONAL INSURED(S) Sunrise LQ LLC, Andalusia Country Club LLC, Riverside County Fire Department, CAL Fire, All subsidiaries and their respective agents, officers, members, directors, employees, successors and assigns, as additional insureds. DISPLAY LOCATION DISPLAY DATE(S) Andalusia Country Club 11/7/2020 It is certified that this policy requires a 30 day mutual notice of cancellation between the Insurer and the Named Insured. In the event of such cancellation we will endeavor to mail 10 days written notice to the Additional Insured(s), whose name and address is shown hereon, but failure to mail such notice shall impose no obligation or liability of any kind upon the insurer and/or the undersigned. DRAYTON INSURANCE BROKERS, INC. 10/7/2020 DATE OF ISSUE A.J. STRINGER, PRESIDENT 6 0 0 ' - 2 "