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FPYR2019-0005Description: THE GOLF CLUB AT LQ / PYRO / APRIL 4 2019 Type: FIRE PYROTECHNICS Subtype: Status: APPROVED Applied: 3/21/2019 AMA Approved: 4/1/2019 EGO Parcel No: 764270041 Site Address: 60151 TRILOGY PKY PKY LA QUINTA,CA 92253 Subdivision: TR 30023-1 Block: Lot: 136 Issued: Lot Sq Ft: 0 Building Sq Ft: 0 Zoning: Finaled: Valuation: $0.00 Occupancy Type: Construction Type: Expired: No. Buildings: 0 No. Stories: 0 No. Unites: 0 Details: 111 �J Applied to Approved Printed: Tuesday, February 14, 2023 9:57:47 AM 1 of 3 WSYSiEMS ADDITIONAL • NAMETYPE NAME ADDRESSI CITY STATE ZIP PHONE FAX EMAIL APPLICANT FIREWORKS & STAGE FX AMERICA, LLC POBOX 488 LAKESIDE CA 92040 Z.SANTOS@FIREWORK SAMERICA.COM BILL TO FIREWORKS & STAGE FX AMERICA, LLC POBOX 488 LAKESIDE CA 92040 Z.SANTOS@FIREWORK SAMERICA.COM OWNER TLQ PARTNERS 1600 N LA HABRA HILLS DR LA HABRA CA 92253 Printed: Tuesday, February 14, 2023 9:57:47 AM 1 of 3 WSYSiEMS Printed: Tuesday, February 14, 2023 9:57:47 AM 2 of 3 WsYsrEMS REVIEWS ■ CLTD DESCRIPTION ACCOUNT CITY AMOUNT PAID PAID DATE RECEIPT # CHECK # METHOD PAID BY NOTES DATE BY FIRE PYROTECHNICS 101-0000-42421 0 $320.00 $320.00 3/21/19 R46784 14628 CHECK FIREWORKS & STAGE AMA 3/21/2019 COMPLETE THE REMAING BALANCE OF $5 BEFORE WE CAN DAY) MAGALLON FX AMERICA, FIRE PYROTECHNICS PC 101-0000-42420 0 $400.00 $400.00 3/21/19 R46784 14628 CHECK FIREWORKS & STAGE AMA 3/21/2019 4/2/2019 4/1/2019 APPROVED- THE PERMIT IS DIGITALLY ATTACHED. GONZALEZ FX AMERICA, Total Paid for FIRE FEES: $720.00 $720.00 RECORDS 101-0000-424160 $10.00 $10.00 3/21/19 R46784 14628 CHECK FIREWORKS & STAGE AMA MANAGEMENT FEE FX AMERICA, Total Paid for RECORDS MANAGEMENT FEE: $10.00 $10.00 TECHNOLOGY 502-0000-436110 $5.00 $5.00 3/28/19 R47078 14652 CHECK FIREWORKS & STAGE AMA ENHANCEMENT FEE FX AMERICA, Total Paid for TECHNOLOGY ENHANCEMENT FEE: $5.00 $5.00 TOTALS:00 $735.00 Printed: Tuesday, February 14, 2023 9:57:47 AM 2 of 3 WsYsrEMS REVIEWS RETURNED STATUS REMARKS REVIEW TYPE REVIEWER SENT DATE DUE DATE NOTES DATE 1ST PERMIT TECH (1 ARMANDO PERMIT PROCESSED. APPLICANT NEEDS TO PAY 3/21/2019 3/22/2019 3/21/2019 COMPLETE THE REMAING BALANCE OF $5 BEFORE WE CAN DAY) MAGALLON ISSUE THE PERMIT. IST FIRE (2 WK) EDGAR 3/21/2019 4/2/2019 4/1/2019 APPROVED- THE PERMIT IS DIGITALLY ATTACHED. GONZALEZ CONDITIONS Printed: Tuesday, February 14, 2023 9:57:47 AM 2 of 3 WsYsrEMS Printed: Tuesday, February 14, 2023 9:57:47 AM 3 of 3 WsYsrEMS ATTACHMENTS Attachment Type CREATED OWNER DESCRIPTION PATHNAME SUBDIR ETRAKIT ENABLED DOC 3/21/2019 ARMANDO MAGALLON CITY OF LQ CITY OF LQ0 APPLICATION APPLICATION.pdf IST SUBMITTAL - 1ST SUBMITTAL - DOC 3/21/2019 ARMANDO MAGALLON APPLICATION AND APPLICATION AND 0 DETAILS DETAILS.pdf FPYR2019-0005 - GOLF FPYR2019-0005 - GOLF CLUB AT LQ - 60-151 CLUB AT LQ - 60-151 DOC 4/1/2019 EDGAR GONZALEZ TRILOGY PKWY - TRILOGY PKWY - 1 PERMIT APPLICATION PERMIT APPLICATION AND APPROVAL.pdf AND APPROVAL.pdf Printed: Tuesday, February 14, 2023 9:57:47 AM 3 of 3 WsYsrEMS C(V Qa CALIFORNIA r ` DESIGN & DEVELOPMENT DEPARTMENT 4� 78-495 Calle Tampico La Quinta, California 92253 (760) 777-7125 FAX (760) 777-7011 FIRE REVIEW APPLICATION O NEW ❑ TENANT IMPROVEMENT PERMIT NO. PROJECT INFORMATION (Please Print) Project Name: The Golf Club at La Quinta Sign: zeal s�� Site Address: 60151 Trilogy Parkway Print: Zelmy Santos City & Zip: La Quinta, CA 92553 • 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: Fireworks America Contractor #: Contact Person: Zelmy Santos Contact Person: Mailing Address: P.O. BOX 488 Mailing Address: City & zip: Lakeside, CA 92040 City & Zip: Phone Number: 619-938-8277 Fax: 619-938-8273 Phone Number: Fax: Email: z.santos@fireworksamerica.com Email: A. APPLICATION TYPE FIRE SPRINKLER SYSTEM SUPRESSION SYSTEM 0 NEW COMMERCIAL/INDUSTRIAL ------------ ❑ HOOD & DUCT $415 0 0-35,000 SQ FT $655 ❑ SPRAY BOOTH $816 0 35,001-75,000 SQ FT $775 ❑ CELL SITE $816 0 75,001-120,000 SQ FT $976 0 OTHER SUPRESSION SYSTEM $816 0 120,001 AND UP $1216 MISC 0 TI COMMERCIAL/INDUSTRIAL $415 ❑ HAZMAT $335 ❑ RESIDENTIAL - 1sT DWELLING UNIT $415 ❑ HIGH PILE RACK STORAGE $335 O RESIDENTIAL - (EA) ADDITIONAL x $175 ❑ NEW COMMERCIAL - U/G WATER $495 13 MULTI -FAMILY (3 OR MORE) $575 ❑ FIRE FLOW REPORT $335 FIRE ALARM SYSTEM ❑ TECHNICAL REPORT RESEARCH HOURLY@ $160/HR ❑ COMMERCIAL - SPRINKLER MONITORING $415 ❑ SPECIAL INSPECTION $165 ❑ COMMERCIAL - FIRE ALARM SYSTEM $1056 0 FIRE PUMPS $655 FIRE ALARM SYSTEM 0 STANDPIPE SYSTEMS $575 ❑ COMMERCIAL - SPRINKLER MONITORING $415 ❑ WATER TANKS $415 0 COMMERCIAL - FIRE ALARM SYSTEM $1056 ❑ MASTER PLAN HOURLY @ $160/HR STORAGE TANKS ❑ MASTER PLAN REVISION HOURLY @ $160/HR 0 DISPENSERS ONLY HOURLY @$160/HR **P rotechnics Display" O ABOVE GROUND HOURLY @ $160/HR Each application type includes a Technology Enhancement Fee55 & Records Management Fee $10 REVISEU 9/17/2018 Riverside County Fire Department Riverside Office: 2300 Market Street, Ste. 150 Riverside, CA 92501 Phone: (951) 955-4777 - Fax: (951) 955-4886 PLAN REVIEW FORM IN New ❑ Re -Submittal # ❑ As-builts Permit No. Project Information (Please Print) Project Name: The Golf Club at La Quinta Address: 60151 Trilogy Parkway City & Zip: La Quinta, CA 92553 Contact Information CONTACT PERSON: Zelmy Santos Mailing Address: PO Box 488 City & Zip Lakeside, CA 92040 Phone No.: 619-938-8277 Fire Protection Planning Palm Desert Office: 77-933 Las Montanas Rd., Ste 201 Palm Desert CA 92211 Phone: (760) 863-8886 - Fax: (760) 863-7072 Office Use Only Plans Received I have read and understand that Fire Dept. fees are Deposit Based Fees and there may be additional money due pri r to or after project final. Sign: Z&Unq Saniv-gr Print: Zelmy Santos Billing Information 0 Same as Contact Info BILL TO: Mailing Address: City & Zip Fax: 619-938-8273 Phone No.: Email: z.santos@fireworksamerica.com Email: Fax: 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) ❑ Commercial ❑ Industrial ❑ Residential 0 Special Event 0 Other ❑ Building ❑ Building Tenant Improvement ( New / Existing ) ❑ High Fire Area ❑ Sprinkler System ❑ TI Sprinkler System ❑ Sprinkler Monitoring ❑ Fire Alarm System ❑ Hood & Duct Suppression System ❑ Other Suppression System ❑ Spray Booth ❑ Cell Site ❑ High Pile/Racks 0 Other: pyrotechnics ❑ Underground Water Storage Tank Submittals. ❑ Dispensers Only ❑ Above Ground ❑ Underground Form I — Revised 7/25/2012 Visit us at www.rvcfire.or Office Use Only Fee Paid: Called for Pick -Up Reviewed by: E_ �o�.za�.E� Date: By: Date Paid: PC Review Date: '-� �r - Picked -Up Check#: gApproved ❑ Denied Date: By: Received By: Plans Stamped: 9yes ONO Shipped By / Method Letter Attached: ❑Yes J No Receipt#(OCR) Job Card Included: ❑Yes KNo ❑DBF ❑DBF ❑DBF (PYrzo) Form I — Revised 7/25/2012 Visit us at www.rvcfire.or RIVERSIDE COUNTY FIRE DEPARTMENT li6 FIRE PREVENTION PUBLIC FIREWORKS DISPLAY PERMIT APPLICATION PLEASE PRINT OR TYPE, INCOMPLETE APPLICATIONS WILL BE RETURNED. Choose: ❑ FIREWORKS PROGRAM ❑ FIRE PROTECTION PLANNING - EAST either: PO BOX 2047 77933 LAS MONTANAS RD. STE #201 PERRIS CA 92572-2047 PALM DESERT CA 92211-4131 APPLICATIONS SHALL BE SUMITTED 10 DAYS PRIOR TO THE DISPLAY. I/we hereby make application for a permit to conduct a public fireworks display as defined by the California State Health and Safety Code, and agree to comply in every particular with the law pertaining thereto as set forth in Part 2 of division 11 of the Health and Safety Code, and the rules I and Regulations adopted by the State Fire Marshal. SPONSORING ORGANIZATION INFORMATION 1. Sponsoring Organization Name:The Golf Club at La Quinta S onsorin Organization Representative: Thomas wn 2. Address: 60151 Trilogy Way La Quinta, CA 92253 PUBLIC DISPLAY INFORMATION 3. Company Name/Address: Fireworks America 4. Public Display License No.: GPD -0528 PO Box 488 Matt Monge Phone Number/Fax: Lakeside, CA 92040 Name: 619-938-8277/619-938-8273 10. Pyrotechnic Operator Assistants: EVENT INFORMATION 5. Date of Display: 04-06-19 6. Times: 9:00-9:1 Opm From: M To: M 7. Exact location of display (see Note t) The driving range at the Golf Club at La Quinta PYROTECHNIC OPERATOR INFORMATION 8. Pyrotechnic Operator supervising discharge of fireworks: 9. State License Number: Matt Monge 3411-02 Name: Phone Number: 714-381-0097 10. Pyrotechnic Operator Assistants: 11. Name: TBD Name: TBD 12. Name: 13. Name: TBD TBD PRODUCT INFORMATION 14. Class of fireworks to be displayed: (see Note 2) Aerial please see attached 15. Number of items (s eci if single or multiple break) 2- multi -shot bombardments 16. Number of set pieces N/A 17. Other items to be displayed (describe) Fireworks America 18. Name of wholesaler supplying all items used in display: 19. Wholesaler's state license number: W-1 132 20. Name of Importer/Exporter supplying all items used in display: I 21. Importer/Exporter's state license number: Fireworks America I/E-1129 STORAGE INFORMATION 22. Location of fireworks storage PRIOR to display: 23. City and State: Street address: 12485 Hwy 67 North Lakeside, CA 92040 24. Departure date and time from storage location: 25. Route(s) used See attached 26. Location of fireworks storage DURING display: 27. City: Street address: on-site La Quinta 28. Describe provisions for return of unused/unfired product after 29. Location of storage of unused/unfired product if applicable 1 dis la . Returned to bunkers 12485 Hwy 67 N Lakeside, CA 92040 PUBLIC FIREWORKS DISPLAY PERMIT APPLICATION INSURANCE INFORMATION 30. Policy number of Employees Compensation Insurance (see Note attach copy to Permit 9080254-2018 31. Policy number of Public Liability Insurance attach co CPP010456806 In affirming my signature hereon, I realize that as the permittee, I am responsible for compliance with all provisions under which this permit may be granted, including the filing of reports required by Title 19, California Code of Regulations. I further affirm that 1 am an authorized a eat for the public dispifty license listed hereon. as required by California Health and Safety Code, Section 12583. APPLICANT'S SIGNATURE S� DATE: 03/08/2019 Use space below for additional information (attach additional sheet(s) if necessary) NOTES 1. Provide dimensioned plot plan diagramming the area, which the display is to be held. Plot plan shall include the placement of devices, location from where operator will discharge fireworks, location of any performers, location of the audience and the lines behind which the audience will be restrained Additionally, show the location of highways, overhead obstructions, nearby trees, telephone lines and other lines of communication. When necessary, a sectional drawing shall be provided. 2. Include complete description of all fireworks to be displayed, specifying if single or multiple break shells. If set pieces are used, they shall be described in detail. Provide complete description of additional items to be displayed. 3. Insurance Required: An original Certificate of Insurance must be filed with this application, which complies with the following requirements (refer to Section 993, Title 19 and 12611, California Health & Safety Code): • The deductible (if any) may not exceed fifteen thousand dollars ($15,000.00). Limits of bodily injury and property damage may be not less than one million dollars ($1,000,000.00) combined single limits for each occurrence annually. • A statement must be included that the insurer will not cancel the insured's coverage without 15 days prior written notice to the State Fire Marshal and the Riverside County Fire Department. • The County of Riverside / Fire Department shall not be responsible for any premiums or assessments involving the policy. • The licensed pyrotechnic operator supervising/discharging the display and the State of California, its officers, agents, employees, and servants must be included as additional insured's OFFICE USE ONLY BELOW LINE mit for Transportation of Fireworks for Display to be held: FTE) is Hereby: Granted ✓ Denied Name: Title: s1gsc SpEc�oa! rr Signature: Date: +e, _ � 9 Permit for Public Display of Fireworks to be held: DATE is Hereby. Granted ✓ Denied Name: Title: �i.QE S,o ' �.o6ci ac rsr Signature: Date: CONDITIONS and/or RESTRICT'IQ1NS -I-We- L0,00 0W.17pIECrl0N OE@C//41619 de_ u-We6 /Q 60 ✓cT /S i.e fi6727,4Ar *AUTHORITY HAVING JURISDICTION RESERVES AUTHORITY TO MAKE CHANGES TO THIS PERMIT UPONANY CONDITION(S) kNN11lL;dL1U11 iur rVn111L iur d 'ublic Display of Pyrotechnics Lithorily having Jurisdiction: .nisser Valdez iverside County Fire Dept. (CAL Fire) 1933 Las Montanas Road :e 201 alm Desert, CA 92211 19032 Client: The Golf Club at La Quinta Attn: Thomas Brown 60151 Trilogy Pkway La Quinta, CA 92253-7640 r. V. [.gun -too Fire orhs Lakeside, CA 92040-0488 P ; , , , t „ (619) 938-8277 America Fax (619) 938-8273 reworks & Stage FX America, Inc. on behalf of the Sponsor Listed Above requests a permit to )nduct a public display of fireworks in accordance with Federal, State and Local Laws and Ordinances. ate(s): 4/6/2019 me/Length: 9PM 10 Min yrotechnic Matthew Monge 3411-02 perator(s) (operator Name) (License No.) id License and assistants. umber: Nhere required) Matthew Cell: 714-381-0097 x 1 Email: cy-presslights(W-amail.com Site Information: The Driving range at The Golf Club at La Quinta 60151 Trilogy Pkway La Quinta, CA 92253 'oof of current General Liability Insurance and Workers Compensation Insurance is attached. detailed diagram of the proposed firing site is attached ascription of Display: The Golf Club at La Quinta on 4/6/2019 in La Quinta, CA. Fireworks fired Electrically, by Computer, in Racks. round Level Pyrotechnics (0 - 50 Foot typical Altitude): )w Level Pyrotechnics (51 - 125 foot typical altitude): Mines - 2 in - 80; Bombardments - 2; arial Pyrotechnics (>125 foot typical altitude): Single Break Aerial Shells: 3 in - 225; 4 in - 52; 5 in - 24; Multi -Break Aerial Shells: Office contact: Zelmy Santos (619) 938-8277, Fax (619) 938-8273 RMISSION TO CONDUCT A PUBLIC DISPLAY OF PYROTECHNICS AS SPECIFIED HEREIN HEREBY: PERMITTED DENIED E 401VZ6cFZ Circle Appropriate Sign ure of Date Pe,- CT ton/ ,ZEQV,.-60 • � 2 -�� �i,2 E s.�r sP6ci ou,! T Title M U �9 C � � � +-r i ip U �• GJ i 13 � a i 'y �r, L O .J . •'� `�,O QO C 40 w-�r a. �- ...ate �`=�••w��� "�" �" �... � �►�-- Aftwk ad y� r � K '�" yr • � L Q] � va 5 f ti � 4 ip_ P �- ...ate �`=�••w��� "�" �" �... � �►�-- Aftwk ad y� r � K 3/8/2019 12485 CA -67, Lakeside, CA 92040 to The Golf Club at La Quinta - Google Maps GO)gle Maps 12485 CA -67, Lakeside, CA 92040 to The Golf Club at La Quinta Drive 123 miles, 2 h 29 min 12485 CA -67 Lakeside, CA 92040 t 1. Head west on Vigilante Rd Continue on CA -67 N. Take CA -78 E/Julian Rd, CA -79 N, Montezuma Valley Rd, Borrego Salton Seaway,... and Old California 86 to Trilogy Pkwy in La Quinta 2 h 29 min (123 mi) r' 2. Turn right onto CA -67 N 15.2 mi t 3. Continue onto Main St 0.9 mi t 4. Continue onto CA -78 E/Julian Rd 14.4 mi '1 5. Turn left onto CA -79 N 11.4 mi r' 6. Turn right onto San Felipe Rd 4.7 mi h 7. Turn left onto Montezuma Valley Rd 17.4 mi r► 8. Turn right onto Palm Canyon Dr 1.4 mi 9. At Christmas Cir, take the 4th exit and stay on Palm Canyon Dr t 10. Continue onto Pegleg Rd t 11. Continue onto Borrego Salton Seaway 13.1 mi t 12. Continue onto Borrego Salton Sea Way 6.5 mi *1 13. Turn left onto Sunrise Dr 1.3 mi *1 14. Turn left onto CA -86 N 14.1 mi 1 15. Turn left onto 81st Ave/Old California 86 0.3 mi r' 16. Turn right onto Harrison St/Old California 86 12.0 mi 41 17. Turn left onto Avenue 60 35mi *, 18. Turn left onto Trilogy Pkwy 31 s (0.1 mi) The Golf Club at La Quinta https://www.google.com/maps/dir/12485+CA-67,+Lakeside,+CA+92O40lfhe+Golf+Club+at+La+Quinta,+Trilogy+Parkway,+La+Quinta,+CA/@33.4206..- 1/2 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 3/8/2019 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). PRODUCER CONTACT Nau The The Partners Group Ltd PHONE FAX 11225 SE 6th St., Suite 110 IA/C. No. Ed). 425-455-5640 (A/C No): 425-455-6727 Bellevue WA 98004 EMAIL REss: 'nau@tpgrp.com INSURERS AFFORDING COVERAGE NAIC # INSURERA: T.H.E. Insurance Company 12866 _ INSURED 14567 INSURER B: Fireworks and Stage FX America, Inc. Fireworks and Stage FX America, LLC INSURER C : INSURER D: PO Box 488 Lakeside CA 92040-0488 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1594701275 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 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. ILT R1 TYPE OF INSURANCE POLICY EFF POLICY EXP LTR . POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS A GENERAL LIABILITY Y CPP010456806 1/11/2019 1/11/2020 EACH OCCURRENCE $ 1,000,000 X A A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE EI OCCUR PREMISES Ea occurrence $100,000 MED EXP (Any oneperson) $ Excluded PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $ 10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 X POLICY ARO- LOC $ A AUTOMOBILE LIABILITY CPP010456806 1/11/2019 1/11/2020 COMBINED SINGLE= LIMrr BODILY INJURY (Per person) $ ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ I ) X _ HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ p 1 X �y {100 X Coll $1,000 $ A_ UMBRELLA LIAB X OCCUR ELP001296300 1111/2019 1/11/2020 EACH OCCURRENCE $5.000:000 X AGGREGATE $ 5,000,000 EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ GL Onl WORKERS COMPENSATION WC STRTU- OTH- AND EMPLOYERS' LIABILITY Y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E L. EACH ACCIDENT $ E. L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS below A A ExcessLiab — Auto Hired Auto Phys. Dmg. Limit 586,(700 TRK $25,000 Trl ELP001239902 CPP010456806 1/11/2019 1/11/2019 1/11/2020 1/11/2020 Each Occurrence 4,000,000 Aggregate 4,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Excess Liability - GL $14M XS $5M - Policy #ELP001179206 - T H. E. Insurance Company - Effective 1-11-19 to 1-11-20 Show date: 04/06/19 Show location: The Golf Club at La Quinta The Golf Club at La Quints, City of La Quinta, The County of Riverside; its officers, agents, employees, and servants when acting in their official capacity as such. The duly licensed pyrotechnic operator required by law to supervise and discharge the publrc 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 are included as additional insureds per written contract CERTIFICATE HOLDER CANCELLATION The Golf Club at La Quinta 60151 Trilogy Pkwy La Quinta CA 92253-7640 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ACQRff CERTIFICATE OF LIABILITY INSURANCE �.I DATE(MMIDD/YYYY) IF 1/10/2019 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). PRODUCER CONTACT Janet Nau NAME: The Partners Group Ltd PHONE Ext)(877)455-5640 {A1C, Na}: (425) 455 (Af11225 SE 6th St. EMAIL ADDRESS: nau@t pgrp . com Suite 110 Excluded INSURER(S) AFFORDING COVERAGE NAIC # Bellevue WA 98004 INSURERA:T.H.E. Insurance Company 12866 INSURED INSURER B: Fireworks and Stage FX America, Inc. INSURERC: Fireworks and Stage FX America, LLC INSURERD: PO BOX 488 INSURERE; Lakeside CA 92040-0488 INSURER F: COVERAGES CERTIFICATE NUMBER -19-20 RF►IICfntJ MIIIIAQCD• 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 M=R POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MIJ100IYYYY) iM r0D1YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 A CLAIMS -MADE X OCCUR DAMAGE: TO RENTED PREMISES (Ea occurrence) S 10(], 000 CPP010456806 1/11/2019 1/11/2020 MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10, 000 , 000 %t POLICY, PRO- JECT LOC PRODUCTS - COMPIOP AGG 5 2 , 000 , 000 OTHER $ AUTOMOBILE LIABILITY IN LE LIMIT 5 EO aoc 1,000,000 A ANY AUTO CPP010456806 den/) BODILY INJURY (Per person) S ALL OWNED X SCHEDULED Hired Physical Damage 1/11/2019 1/11/2020 AUTOS AUTOS Y 4 BODILY INJURY (Per S ( ) XHIRED AUTOS X NON -OWNED Comp. Ded $1,000 AUTOS PROPERTY DAMAGE $ (Per aceddent) X Hired PD Coll. Ded $1,000 $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS -MADE AGGREGATE $ 51000,000 DED RETENTIONS ELP001296300 1/11/2019 1/11/2020 $ GL Only WORKERS COMPENSATION PER 0711 - AND EMPLOYERS' LIABILITY YIN STATUTE ER ANY PROPRIETORIPARTNER/EXECUTIVE - OFFICER/MEMBER EXCLUDED? N / A E -L. EACH ACCIDENT $ (Mandatory in NH) E L. DISEASE - EA EMPLOYEE $ If yes, HeSuibe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT $ A Excess Liability — Auto ELP001239902 1/11/2019 1/11/2020 Each Occurrence $4,000,000 Aggregate $4,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance *Evidence of Insurance* ACORD 25 (2014/01) INS025 (201401) LAF4Ur_LLA I IUIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE U 19BB-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '�cE�►�o"� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 1/10/2019 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(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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME Janet HELL The Partners Group Ltd PHONE(877)455-5640 FAX (425)455-6727 _(AIC, No, Ext): (A1C, No): 11225 SE 6th St. E.MA(L ADDRESS: j nauWt r com pg p Suite 110 $ Excluded INS URERIS) AFFORDING COVERAGE NAfC 0 Bellevue WA 98004 INSURERA:T.H.E. Insurance Company 12866 INSURED INSURER B - Fireworks and Stage FX America, Inc. t'SURERC: Fireworks and Stage FX America, LLC INSURER 0: PO Box 488 INSURER E : Lakeside CA 92040-0488 INSURER F: COVERAGES CERTIFICATE NUMBER:19-20 RFVICIn Id kit Ifu1121=12• 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 SUBR POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMILD�lYYYYF MMIDDIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100, 000 CPP010456806 1/11/2019 1/11/2020 MED EXP (Any one person) $ Excluded PERSONAL 8 ADV INJURY 0 1,000, 000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10, 000,000 X PRO POLICY PRO- JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMB] NEGt) ING LE i IMIT $ 1, 000,000 (Ea acciden A ANY AUTO CPP010456806 BODILY INJURY (Per person) $ ALL OS X SCHEDULED Hired Physical Damage 1/11/2019 1/11/2020 '. AUTOS AUTOS �' 3 BODILY INJURY Per accident ( ) $ X HIRED AUTOS X NON -OWNED Com Dd $1, 000 P' e PROPERTY DAMAGE AUTOS (Per accident)S X Hired PD Coll. Ded $1, 000 g UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 510001000 A X_ EXCESS LIAB _ CLAIMS -MADE AGGREGATE $ 51000,000 DED RETENTIONS ELP001296300 1/11/2019 1/11/2020 g GL Only WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N I A EL EACH ACCIDENT $ (Mandatory in NH) EL DISEASE - EA EMPLOYEE $ Ir yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT S A Excess Liability — Auto ELP001239902 1/11/2019 1/11/2019 Each Occurrence $4,000,000 Aggregate $4,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCFLI ATInN Office of the State Fire Marshal Po Box 944246 Sacramento, CA 94244-2460 ACORD 25 (2014/01) INS025 (201401) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Jordan Stair/CCRUDE © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CALIFORNIA DEPARTMENT OF FORESTRY and FIRE PROTECTION OFFICE OF THE STATE FIRE MARSHAL FIREWORKS L License Type: I/E-1129 Issue Date: 04/30/2018 Licensee: FIREWORKS & STAGE FX AMERICA ATTN: ROBERT WOZNIAK P.O. BOX 488 LAKESIDE, CA 92040-0488 The named licensee is authorized to perform all acts permitted a fireworks IMPORTER/EXPORTER pursuant to Part II, Chapter I of the Health and Safety Code of the State of California. Expires: 6/30/2019 �puty State Eii� arshal nN-IOJ02-14-01y CALIFORNIA DEPARTMENT OF FORESTRY and FIRE PROTECTION OFFICE OF THE STATE FIRE MARSHAL FIREWORKS LICENSE License Type: GPD -0528 Issue Date:. 04/30/2018 Licensee: FIREWORKS & STAGE FX AMERICA ATTN: ROBERT WOZNIAK P.O. BOX 488 LAKESIDE, CA 92040-0488 The named licensee is authorized to perform all acts permitted a fireworks PUBLIC DISPLAY (GENERAL) pursuant to Part II, Chapter I of the Health and Safety Code of the State of California. Expires: 6/30/2019 Deputy state Fire Marshal FM -10(02-14-01) CALIFORNIA DEPARTMENT OF FORESTRY and FIRE PROTECTION OFFICE OF THE STATE FIRE MARSHAL FIREWORKS LICENSE License Type: W-1132 Licensee: FIREWORKS 6 STAGE FX AMERICA ATTN: ROBERT WOZNIAK P.O. BOX 488 LAKESIDE, CA 92040 Issue Date: 04/30/2018 The named licensee is authorized to perform all acts permitted a fireworks WHOLESALER pursuant to Part II, Chapter I of the Health and Safety Code of the State of California. Deputy State Fii�q marshal Expires: 6/30/2019 en -10(02-14-01) '4�� EP CERTIFICATE OF LIABILITY INSURANCE FDATE(MM/DD/YYYY) 6/1/2018 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). PRODUCER CONTACT AME CT `Yenta Hewett Whiteboard Risk & Insurance Solutions, LLC PH do Ext#- (858)223-1170 [AX,No): (95a)299.0130 JAf3665 Ruffin Rd. ADORE&s: solutions@whiteboardrisk.com Suite 307 INSURER[SI AFFORDING COVERAGE NAIC a San Diego CA 92123 INSURERA;State Compensation Insurance Fund 35076 INSURED INSURERS: Fireworks & Stage FX America, LLC INSURER CI DBA: Fireworks America INSURER D: P.O. Box 488 INSURERS: Lakeside CA 92040 INSURER F: COVERAGES CERTIFICATE NUMBER'CL186102701 REV DESCRIPTION ISION 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 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 iADDL SUSR POLICY EFF POI,.lCY EXP LTR TYPE OF INSURANCE - . PDi,tCY NUMBER MMIDDIYYYY NIN11 D1YYY1Y1 LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES tEa occurrence) $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO- [ I LOC POLICY I I PRODUCTS -COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acedent) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) S HIRED AUTOS NON-OWNED PROPERTY DAMAGE S (Per accndont) �g UMBRELLA LIAROCCUR HCLAIMS-MADE EACH OCCURRENCE $ EXCESS LIAB AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATIONPER X OTH- AND EMPLOYERS' LIABILITY YIN 1 STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? u N / A = E L EACH ACCIDENT 1,000,000 A (Mandatory in NH) 9080254-18 6/1/2018 6/1/2019 E L DISEASE - EA EMPLOYEE ;� 1,000,000 If yes, describe under OE SCRIP71ON OF OPFRATlnNC hclnw L&H-0904878-18 6/1 /2nl R a/i /7ni o - - _ - --- -_ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Proof of Insurance. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Fireworks & Stage FX America THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN dba: Fireworks America ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 488 Lakeside, CA 92040 AUTHORIZED REPRESENTATIVE Jenn Hewett/JENN &Alt&.ACAw� U 1958-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD NS025 (201401)