Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
FPYR2021-0003
ADDITIONAL SITES CHRONOLOGY CHRONOLOGY TYPE STAFF NAME ACTION DATE COMPLETION DATE NOTES E-MAIL KOHL HETRICK 10/6/2021 10/6/2021 office@fireworksamerica.com Hello, I was beginning my review of the proposed show and observed that our standard department form had not been completed provided. Please, at your earliest convenience – complete, scan and email me the completed form that is attached. Thank you, KOHL HETRICK CONDITIONS Description: PUBLIC FIREWORKS - WEDDING - 10/30/2021 Type: FIRE PYROTECHNICS (WEB)Subtype: Status: FINALED Applied: 9/30/2021 EPRS Parcel No: 777070043 Site Address: 80440 HIDEAWAY CLUB CT LA QUINTA,CA 92553 Approved: 10/12/2021 KHET Subdivision: TR 32453 Block: Lot: 30 Issued: 10/12/2021 AHI Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: 10/30/2021 KHET Valuation: $3,000.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: Printed: Friday, February 24, 2023 2:45:44 PM 1 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0003 CONTACTS NAME TYPE NAME ADDRESS1 CITY STATE ZIP PHONE FAX EMAIL APPLICANT Julie Andrews PO Box 488 Lakeside CA 92040 (619)938-8277 office@fireworksameri ca.com OWNER ND LA QUINTA PARTNERS P O BOX 1482 LA QUINTA CA 92553 (619)938-8277 sunny@hideawaygolfcl ub.com INSPECTIONS SEQID INSPECTION TYPE INSPECTOR SCHEDULED DATE COMPLETED DATE RESULT REMARKS NOTES FIRE FINAL**KHET 10/30/2021 10/30/2021 APPROVED REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED 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 $834.00 $834.00 10/12/21 WEB9549 632933728 23 CREDIT Julie Andrews EPRS FIRE PYROTECHNICS PC 101-0000-42420 0 $167.00 $167.00 10/12/21 WEB9549 632933728 23 CREDIT Julie Andrews EPRS Total Paid for FIRE FEES: $1,001.00 $1,001.00 RECORDS MANAGEMENT FEE 101-0000-42416 0 $10.00 $10.00 10/12/21 WEB9549 632933728 23 CREDIT Julie Andrews EPRS Total Paid for RECORDS MANAGEMENT FEE: $10.00 $10.00 TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 $5.00 10/12/21 WEB9549 632933728 23 CREDIT Julie Andrews EPRS Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 $5.00 TOTALS:$1,016.00 $1,016.00 Printed: Friday, February 24, 2023 2:45:44 PM 2 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0003 ATTACHMENTS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 9/30/2021 Etrakit Public Registration 1ST SUBMITTAL APPLICATION AND PLANS Permit Application_Farren Halcovich_10-30.pdf 1 DOC 10/12/2021 KOHL HETRICK Cal Fire Permit_Farren Halcovich_10-30.pdf Cal Fire Permit_Farren Halcovich_10-30.pdf 1 DOC 10/12/2021 KOHL HETRICK Delete FPYR2021-0003 - RVC FW CHECKLIST.pdf 0 DOC 10/12/2021 KOHL HETRICK FPYR2021-0003 - APPROVED PERMIT.pdf FPYR2021-0003 - APPROVED PERMIT.pdf 1 DOC 11/1/2021 KOHL HETRICK FPYR2021-0003 - RVC FW CHECKLIST.pdf FPYR2021-0003 - RVC FW CHECKLIST_1.pdf 1 BOND INFORMATION DATE 1ST PERMIT TECH (1 DAY) PERMIT TECH BUCKET 9/30/2021 10/1/2021 9/30/2021 COMPLETE 1ST FIRE - ETRAKIT (1 WK) KOHL HETRICK 9/30/2021 10/7/2021 10/12/2021 APPROVED SEE ATTACHMENTS Pending completed form. Printed: Friday, February 24, 2023 2:45:44 PM 3 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0003 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 - 14; Ronald Griesinger La Quinta Fire Department (Riverside County Fire Department/CAL FIRE) 78-495 Calle Tampico La Quinta, CA 92253 Farren Halcovich Attn: Farren Halcovich 81083 Soaring Hawk Indio, CA 92201 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. 10/30/2021 App 8PM Site Information: Authority having Jurisdiction:Client: Date(s): Pyrotechnic Operator(s) and License Number: (where required) Hideaway Golf Club 80440 Hideaway Club Dr La Quinta, CA 92253James Davis 3218-02 (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): 19621 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:3 Min Office contact:Julie Andrews (619) 938-8277, Fax (619) 938-8273 James Cell:818-929-5138 Email:djtntent@hotmail.com Farren Halcovich on 10/30/2021 in La Quinta, CA. Fireworks fired Electrically, in Racks. 19621Fireworks & Stage FX Permit Reference No. Printed CERTIFICATE OF INSURANCE ISSUE DATE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LATER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURER(S) AFFORDING COVERAGE INSURER A: INSURED INSURER B: INSURER C: INSURER D: COVERAGES CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL LIABILITY CLAIMS MADE GEN’L AGGREGATE LIMIT APPLIES PER POLICY EACH ACCIDENT $ MEDICAL EXP (Any one person) $ FIRE LEGAL LIABILITY $ GENERAL AGGREGATE $ PRODUCTS-COMP/OPS AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ANY OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ EXCESS LIABILITY FOLLOWING FORM EACH ACCIDENT $ AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY WC STATU- OTH- TORY LIMITS ER $ E.L.EACH ACCIDENT $ E.L. DISEASE-EA EMPLOYEE $ E.L DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 8/5/2021 PROFESSIONAL PROGRAM INSURANCE BROKERAGE DIVISION OF SPG INSURANCE SOLUTIONS, LLC 1304 SOUTHPOINT BLVD., #101 PETALUMA CA, 94954 LLOYD'S OF LONDON Fireworks America; Fireworks and Stage FX America Inc; Fireworks and Stage FX America, LLC; Meeting Facilitators, LLC PO Box 488 Lakeside, CA 92040 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE 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. A 10,000,000 PY/21-0017 02/12/2021 02/12/2022 50,000 10,000,000 Hideaway Golf Club; City of La Quinta; Riverside County; its officers, agents, employees, and servants, ATIMA 80440 Hideaway Club Dr La Quinta, CA, 92253 Hideaway Golf Club; City of La Quinta; Riverside County; its officers, agents, employees, and servants, ATIMA, when acting in their official capacity as such. The duly licensed pyrotechnic operator required by law to supervise and discharge the public display, acting either as an employee of the insured or as an independent contractor and the State of California, its officers, agents, employees, and servants, ATIMA, are included as additional insureds per written contract as respects the Class B Aerial Fireworks display(s) on 10/30/2021 located at Hideaway Golf Club 80440 Hideaway Club Dr La Quinta, CA 92253. This policy provides a two-year extended reporting period from the date of the display. 30-day notice of cancellation applies. 0 149640 115458 D:\Files\Cert85242.pdf D:\CertMaster\Cert85242.pdf 85242 0 CA PY AI 006 6-14 POLICY NUMBER: PY/21-0017 PYROTECHNIC LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED Underwriter's at Lloyd's, London: Referred to in this endorsement as either the “Insurer” or the “Underwriters” This endorsement modifies insurance provided under the following: SECTION III. PERSONS INSURED In consideration of the premium charged for the Policy, it is hereby understood and agreed that the following entity(ies) is an additional insured pursuant to Section III. e), but only as respects the specific Display or Special Effects listed on the attached Certificate of Insurance: Name of Person or Organization (Additional Insured): Hideaway Golf Club; City of La Quinta; Riverside County; its officers, agents, employees, and servants, ATIMA 80440 Hideaway Club Dr La Quinta CA 92253 Any coverage afforded to any above person or entity as an Additional Insured shall apply only with respect to Bodily Injury or Property Damage directly resulting from (1) the Named Insured’s ongoing operations performed for such specific person and entity; or (2) acts or omissions of the Additional Insured in connection with their general supervisions of the Named Insured’s ongoing operations. Coverage for such person or entity as an Additional Insured does not apply to: (i) Personal Injury and Advertising Injury Liability; (ii) Fire Legal Liability; (iii) Employee Benefits Liability; (iv)Bodily Injury or Property Damage which the person or entity is obligated to pay as damages by reason of the assumption of liability under a contract or agreement but this shall not apply to liability for damages the person or entity would have in the absence of the contract or agreement; (v)Property Damage to: (1) property owned, used or occupied by or rented to such person or entity; (2) property in the care custody, or control of such person or entity or over which such person or entity is for any purpose exercising physical control; or (3) any work, including materials, parts or equipment furnished in connection with such work, which is performed for the person or entity by or on behalf of the Named Insured. (vi)Products-Completed Operations Hazards; (vii) Any obligation assumed by the Additional Insured in any contract related to the Display or Special Effects listed in the attached Certificate of Insurance. (viii) Such other Claims, Accidents, offenses, damages and/or liabilities which may be excluded pursuant to Section V. Exclusions of the Policy. All other terms, exclusions and conditions of this Policy remain unchanged. CERTIFICATE OF INSURANCE ISSUE DATE PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR LATER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURER(S) AFFORDING COVERAGE INSURER A: INSURED INSURER B: INSURER C: INSURER D: COVERAGES CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS GENERAL LIABILITY CLAIMS MADE GEN’L AGGREGATE LIMIT APPLIES PER POLICY EACH ACCIDENT $ MEDICAL EXP (Any one person) $ FIRE LEGAL LIABILITY $ GENERAL AGGREGATE $ PRODUCTS-COMP/OPS AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ANY OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ EXCESS LIABILITY FOLLOWING FORM EACH ACCIDENT $ AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS’ LIABILITY WC STATU- OTH- TORY LIMITS ER $ E.L.EACH ACCIDENT $ E.L. DISEASE-EA EMPLOYEE $ E.L DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 2/12/2021 PROFESSIONAL PROGRAM INSURANCE BROKERAGE DIVISION OF SPG INSURANCE SOLUTIONS, LLC 1304 SOUTHPOINT BLVD., #101 PETALUMA CA, 94954 LLOYD'S OF LONDON Fireworks and Stage FX America Inc,; Fireworks and Stage FX America, LLC PO Box 488 Lakeside, CA 92040 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE NAMED INSURED ABOVE FOR THE 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. A 6,000,000 PY/21-0017 02/12/2021 02/12/2022 50,000 6,000,000 TO WHOM IT MAY CONCERN Certificate of insurance is issued as proof of insurance only as respects the General Liability coverage. 0 149640 115458 D:\Files\Cert70224.pdf D:\CertMaster\Cert70224.pdf 70224 0 CA ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER: $ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 5/26/2021 (858) 223-1170 (858) 223-1170 35076 Fireworks & Stage FX America, LLC DBA Fireworks America P.O. Box 488 Lakeside, CA 92040 A 9080254-2021 6/1/2021 6/1/2022 1,000,000 1,000,000 1,000,000 A USLH L&H 905100-21 6/1/2021 Limit 1,000,000 Proof of Insurance. Proof of Insurance FIRE&ST-01 EHUERTA Whiteboard Risk & Insurance Solutions, LLC8787 Complex Drive Ste 202San Diego, CA 92123 John Tillery solutions@whiteboardrisk.com State Compensation Ins Fund X 6/1/2022 FIREWORKS & STAGE FX AMERICA 12485 CA 67 Issue Date :05/18/2021 LAKESIDE, CA, 92040-0488 Expiration Date :06/30/2022 619-938-8277 Licensee : The Public Display - General Fireworks License is issued to the above Licensee by the California Office of the State Fire Marshal and maybe revoked or suspended for errors or for providing incorrect information provided by the applicant or company representatives. This license does not serve as or provide and warranties or guarantees of continued licensure and is subject to investigation. Issued By Vikkie Raby Fire Engineering License Manager Fire Engineering Division Reviewed and Approved By Vijay Mepani Deputy State Fire Marshal Fire Engineering Division OFFICE OF THE STATE FIRE MARSHAL Please visit calfire.govmotus.org for more information on licensing and permitting with CAL Fire Public Display - General LICENSE NUMBER:GPD-0528 FOR FIREWORKS LICENSE Storage Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 Records Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 This license is valid for the following storage and records facilities: Page 1 of 1 FIREWORKS & STAGE FX AMERICA 12485 CA 67 Issue Date :05/18/2021 LAKESIDE, CA, 92040 Expiration Date :06/30/2022 na Licensee : The Wholesaler Fireworks License is issued to the above Licensee by the California Office of the State Fire Marshal and maybe revoked or suspended for errors or for providing incorrect information provided by the applicant or company representatives. This license does not serve as or provide and warranties or guarantees of continued licensure and is subject to investigation. Issued By Vikkie Raby Fire Engineering License Manager Fire Engineering Division Reviewed and Approved By Vijay Mepani Deputy State Fire Marshal Fire Engineering Division OFFICE OF THE STATE FIRE MARSHAL please visit calfire.govmotus.org for more information on licensing and permitting with CAL Fire Wholesaler LICENSE NUMBER:W-1132 FOR FIREWORKS LICENSE Storage Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 Records Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 This license is valid for the following storage and records facilities: Page 1 of 1 FIREWORKS & STAGE FX AMERICA 12485 CA 67 Issue Date :05/18/2021 LAKESIDE, CA, 92040-0488 Expiration Date :06/30/2022 na Licensee : The Importer/Exporter Fireworks License is issued to the above Licensee by the California Office of the State Fire Marshal and maybe revoked or suspended for errors or for providing incorrect information provided by the applicant or company representatives. This license does not serve as or provide and warranties or guarantees of continued licensure and is subject to investigation. Issued By Vikkie Raby Fire Engineering License Manager Fire Engineering Division Reviewed and Approved By Vijay Mepani Deputy State Fire Marshal Fire Engineering Division OFFICE OF THE STATE FIRE MARSHAL Please visit calfire.govmotus.org for more information on licensing and permitting with CAL Fire Importer/Exporter LICENSE NUMBER:I/E-1129 FOR FIREWORKS LICENSE Storage Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 Records Facilities Street Address City Zip 12485 CA 67 LAKESIDE 92040 This license is valid for the following storage and records facilities: Page 1 of 1 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 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 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 ID/Driver’s License Pyro License Signature