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FPYR2021-0004ADDITIONAL SITES CHRONOLOGY 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 BILL TO Julie Andrews PO Box 488 Lakeside CA 92040 (619)938-8277 office@fireworksameri ca.com OWNER LQCC HOLDINGS, LLC 77750 AVENUE 50 LA QUINTA CA 92253 (619)938-8277 CONDITIONS Description: LQ CC Wedding - Fireworks - 11/13/2021 Type: FIRE PYROTECHNICS (WEB)Subtype: Status: FINALED Applied: 10/19/2021 EPRS Parcel No: 658190003 Site Address: 77750 AVENUE 50 LA QUINTA,CA 92253 Approved: 10/28/2021 KHET Subdivision: Block: Lot: Issued: 10/28/2021 AHI Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: 11/13/2021 KHET Valuation: $4,500.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: 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 10/28/21 WEB9748 633250774 71 CREDIT Julie Andrews EPRS Printed: Friday, February 24, 2023 2:51:27 PM 1 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0004 BOND INFORMATION INSPECTIONS SEQID INSPECTION TYPE INSPECTOR SCHEDULED DATE COMPLETED DATE RESULT REMARKS NOTES FIRE FINAL**KHET 11/13/2021 11/13/2021 APPROVED AFM CHRIS COX TO BE FSO REVIEWS REVIEW TYPE REVIEWER SENT DATE DUE DATE RETURNED DATE STATUS REMARKS NOTES 1ST PERMIT TECH (1 DAY) PERMIT TECH BUCKET 10/19/2021 10/20/2021 10/19/2021 COMPLETE 1ST FIRE - ETRAKIT (1 WK) KOHL HETRICK 10/19/2021 10/26/2021 10/28/2021 APPROVED SEE ATTACHMENTS PARENT PROJECTS DESCRIPTION ACCOUNT QTY AMOUNT PAID PAID DATE RECEIPT #CHECK #METHOD PAID BY CLTD BY FIRE PYROTECHNICS PC 101-0000-42420 0 $167.00 $167.00 10/28/21 WEB9748 633250774 71 CREDIT Julie Andrews EPRS Total Paid for FIRE FEES: $1,001.00 $1,001.00 RECORDS MANAGEMENT FEE 101-0000-42416 0 $11.00 $11.00 10/28/21 WEB9748 633250774 71 CREDIT Julie Andrews EPRS Total Paid for RECORDS MANAGEMENT FEE: $11.00 $11.00 TECHNOLOGY ENHANCEMENT FEE 502-0000-43611 0 $5.00 $5.00 10/28/21 WEB9748 633250774 71 CREDIT Julie Andrews EPRS Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 $5.00 TOTALS:$1,017.00 $1,017.00 Printed: Friday, February 24, 2023 2:51:27 PM 2 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0004 ATTACHMENTS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 10/19/2021 Etrakit Public Registration 1ST SUBMITTAL Permit Application - Pyro Display Permit Application_Janille Chambers Wedding_11- 13.pdf 1 DOC 10/28/2021 KOHL HETRICK CalFire Permit_Janille Chambers_11-13.pdf CalFire Permit_Janille Chambers_11-13.pdf 1 DOC 10/28/2021 KOHL HETRICK FPYR2021-0004 -RVC FW CHECKLIST.pdf FPYR2021-0004 -RVC FW CHECKLIST.pdf 0 DOC 10/28/2021 KOHL HETRICK FPYR2021-0004 - APPROVED PERMIT.pdf FPYR2021-0004 - APPROVED PERMIT.pdf 1 Printed: Friday, February 24, 2023 2:51:27 PM 3 of 3 Permit Details City of La Quinta PERMIT NUMBER FPYR2021-0004 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 - 10; Ronald Griesinger La Quinta Fire Department (Riverside County Fire Department/CAL FIRE) 78-495 Calle Tampico La Quinta, CA 92253 Janille Chambers Attn: Janille Chambers , 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. 11/13/2021 ~ 8:50PM Site Information: Authority having Jurisdiction:Client: Date(s): Pyrotechnic Operator(s) and License Number: (where required) La Quinta Country Club 77-750 Avenue 50 La Quinta, CA 92253James D. Bates 3671-02 (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): 21604 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 D.Cell:760-270-7715 Email:jamesmaster79@gmail.com Janille Chambers on 11/13/2021 in La Quinta, CA. Fireworks fired Electrically, in Racks. 21604Fireworks & Stage FX Permit Reference No. Printed Certificate of Insurance Issue Date: PRODUCER Professional Program Insurance Brokerage 1304 Southpoint Blvd., Suite 101 Petaluma, CA 94954 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURED INSURER A: INSURER B: INSURER C: INSURER D: COVERAGES: CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (DD/MM/YY) POLICY EXPIRATION DATE (DD/MM/YY) LIMITS GENERAL LIABILITY CLAIMS MADE EACH ACCIDENT MEDICAL EXP (any one person) FIRE LEGAL LIABILITY GENERAL AGGREGATE PRODUCTS-COMP/ OPS AGG DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Certificate holder is additional insured as respects the following: Date(s) of Display: Location: Additional Insured: Rain Date(s): Type of Display: CERTIFICATE HOLDER AUTHORIZED REPRESENTATIVE 28188 10/4/2021 Fireworks America; Fireworks and Stage FX America Inc; Fireworks and Stage FX America, LLC; Meeting Facilitators, LLC PO Box 488 Lakeside, CA 92040 Underwriter's at Lloyd's, London 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 $10,000,000PY/21-0017 2/12/2021 2/12/2022 $50,000 $10,000,000 11/13/2021 La Quinta Country Club 77-750 Avenue 50 La Quinta, CA 92253 La Quinta Country Club; Janille Chambers; City of La Quinta; County of Riverside; its officers, agents, employees, and servants when acting in their official capacity as such. The duly licensed operator required by law to supervise and discharge the public show, acting either as an employee of the insured or as an independent contractor and the State of California, its officers, agents, employees, and servants are included as additional insureds per written contract. Aerial Fireworks Display La Quinta Country Club 77-750 Avenue 50 La Quinta, CA 92253 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXIPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. 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 04/21/2021 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 10,000,000 PY/21-0017 02/12/2021 02/12/2022 50,000 10,000,000 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