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HomeMy WebLinkAboutCERTIFICATES - 06-00123 - Nelson Fire Systems - Fire Safety CertificationL~ ~~}~ ~J " ~ ~~rn s a ~ a ,,G~~ ~~ ~Y a r O C Z v m A m 3 m W ~ '~ m N O Z m Q "~ ~~ 0 00 0 0 r•~ W r Z ~ ~ ~ r r ~ ~ ~' ~ O ~ ~ z ~ ~ ~ ~ ~ ~ r~ "~ /~~ W r••I i..•~ VI i..~ Vl n m -~ n -~ O Z 'd m 3 -~ m -~ -e -C N -i m Client#• 1 SFIRI ACORDTM CERTIFICATE OF LIABILITY INSURANCE osioiios°"Y'~"' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION UT-COMMERCIAL LINES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR COBB STRECKER DUNPHY & ZIMMERMANN ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 5 TRIAD CENTER SUITE 340 SALT LAKE CITY, UT 84180 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: SCOTTSDALE INSURANCE CO. NELSON FIRE SYSTEMS INSURER B: UNITED FIRE & CASUALTY 1481 SO MAJOR STREET INSURER C: SALT LAKE CITY, UT 84115 INSURER D: INSURER E: rnvcoer_cc v THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT , MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR TYPE OF INSURANCE POLICY NUMBER ~ T M A . !~ GE`:ERAL LiA61'~ITY CLS1251558 ~?6/01/OS 06!01/0a EACH OCCURRENCE $1 000.000 , X COMMERCIAL GENERAL LIABILITY ~ DAMAGE TO RENTED $100 000 CLAIMS MADE a OCCUR MED EXP (Any one person) $5 000 PERSONAL 8 ADV INJURY $1 000 000 GENERAL AGGREGATE $2 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $2 000 000 POLICY PRO LOC B AUT OMOBILE LIABILITY 60037227 06!01!06 06/01/07 COMBINED SINGLE LIMIT $1 000 000 ANY AUTO (Ea accident) , , ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ -_. ~- $ - _.__-_ .__._ _._~__~_~_.___. __~_..v ..-~. - . _ WCSTATU- OTH- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS /LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS RE: ALL OPERATIONS JUN ~- 5 CE CITY OF REXBURG BUILDING DEPARTMENT ATTN: JANELL HANSEN 19 EASET MAIN REXBURG, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _3.0_ 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 REPRESENTATIVE ACQKU ZS (1UU9/US) 1 Of 2 #52Z5Z7S/MZZ5Z6S air ....-..--•-•- ~-•-• --•---••_...___ 19 E. Main St. Rexburg,ldaho 83440 www. rexbu rg. org "SAFETY SYSTEM PERMIT#: U7 CERTIFICATION PERMIT" $100 Fee Pai .Yes o Permit Approved: Yes/No APPLICATION BY: ~ -L`~z ~~"Date: ~ "A safety sysfem certification permit is required to install, modify, maintain, or service all new and existing fire extinguishers, fire suppression systems, fire alarm systems, and other life safety systems within the City of Rexburg" BUSINESS NAME: ^~tls~r ~rrti S~s~evn s Parcel: -- _ „.~ `~ ~~~ ~~' ''' t 1,~ ~ ~1` OFFICE ADDRESS: _ (~I81 s IM.•' n r S~- - S ~ ~- u T- & y r ~ S ~ rt I~ MAR ®7 2006 '~~ , ~~ OFFICE PHONE NUMBER: 8'a I ' '16 $ - Fs30-O I ~~ CONTACT PERSON: Dav i~ $~..~n i CELL PHONE #: $o t - (oS 2-11aj I PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THAT APPLY. FIRE ALARM SYSTEMS -Alarm Contractors shall have a minimum of NICET Level 1 Certifications •PLEASE PROVIDE CERTIFICATIONS: •NICET Certification •Panel Certification •Proof of Liability Insurance AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minimum of NICET Level III Certifications. •PLEASE PROVIDE CERTIFICATIONS: •NICET Certification •Any Additional Certifications •Proof of Liability Insurance FIRE EXTINGUISHERS STANDPIPE SYSTEMS SMOKE CONTROL SYSTEMS SPECIAL HAZARD SYSTEMS FIRE PUMPS AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING ***PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS, LIABILITYINSURANCE, ETC. FOR ALL DIS/PL/NES.*** MAR - ~ ~~~~ ~~.,~ i Phone: 208-359-3020 x326 Fax:208-359-3024 cdd@rexburg.org ,, / ! ~ BUSINESS NAME: I Vc ~3^'~ ~~ r ~ '~y s I-e vYt S PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT: COMPANY NAME: Ft~t C.,~i~-b I rH>~1~-+ w~.n (~ PHONE #: ~~ '27`~ ' `I3 Z- Y COMPANY NAME: G ~ ~-'~~ we. t ( PHONE #: 8 ~ " ~ ° ~ " ~ 9 a~3 COMPANY NAME: l3' o ~ c,~.. PHONE #: ~ °a " ~3 g- Sg' ° 7 *****PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF THIS FORM**** I certify that I have read this application and declare under penalty of perjury that the information contained herein is correct and complete. I agree to comply with all city ordinances, adopted codes, and state laws relating to the installation, modification, service, and maintenance of new and existing life safety systems. I hereby authorize representatives ofthis city to inspect any work for compliance purposes. I am either the contractor responsible for the work, or I represent the owner as signified above and am acting with the owner's (contractor's full knowledge or consent. ~ar +r B Kr v1 ~ ~~ L,~ PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE ual t 3 ~ -~ ~ 0 6 PERMIT VALID FOR ONE YEAR FROM DATE OF APPROVAL. 4/25/2006 Time: 12:47 PM To: JANELL HANSEN @ 9,12083593024 Paqe: 001 Client#: 1177 FIRI CD~DTM CERTIFICATE OF LIABILITY INSUR NCE O4/25/O6D/YYYYI r JUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION UT-COMMERCIAL LINES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE COBB STRECKER DUNPHY 8 ZIMMERMANN HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 5 TRIAD CENTER SUITE 340 SALT LAKE CITY, UT 84180 INSURED NELSON FIRE SYSTEMS 1481 SO MAJOR STREET SALT LAKE CITY, UT 84115 COVERAGES INSURERS AFFORDING COVERAGE NAIC # INSURER A: WESTERN COLONIAL GENERAL AGENC INSURER e. UNITED FIRE & CASUALTY INSURER C. INSURER D: INSURER E: 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. AGGREGATE LIMITS SHOWN MAV HAVE BEEN REnuc En av Paln r.l AIMS V R .TR DD' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/OD/YY POLICY EXPIRATK)N DATE MM/DD/YY LIMITS A GENERAL LIABILITY SCP504091 OF>/O1/O5 OB/O1/OF1 EACH OCCURRENCE $1 OOO 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISS Ea occurrence $100 OOO CLAIMS MADE ~ OCCUR MED EXP (Any one person) $rj QOQ PERSONAL 8 ADV INJURY $1 000 OOO GENERAL AGGREGATE $2 OOO 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPlOP AGG $2 000 000 POLICY PRO LOC JECT B AUTOMOBILE LIABILITY 60037227 06/01/05 06/01/06 COMBINED SINGLE LIMIT E i $1 000 000 ANY AUTO a acc ( d enl) , , ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-0WNEDAUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LU\BILITY AUTO ONLY - EA ACC (DENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ^ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OTH- ' TORY LIMITS ER EMPLOYERS LIABILITY ANY PROPRIETORlPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLO VEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER [~C~t~odC~ p )ESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS tE: ALL OPERATIONS 206 APR Z 6 CI TY OF REXBURG :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF REXBURG DATE THEREOF, THE ISSUING INSURER WILL R9114~2xRxat MAIL ~0_ DAYS WRITTEN BUILDING DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,RxRR91 K ATTN: JANELL HANSEN x~eJORKxatxoa~RmotKraxxe~vae~xxxa~x~xxx~oxoemxRxocoWtxe~c~cxxx>IS~co~cxocxx 19 EASET MAIN xKe~KOCOe~~cxx REXBURG, ID 83440 AUTHORIZED REPRESENTATNE 1CORD 25 (2001/08) 1 of 2 #S221232/M187448 LLH ©ACORD CORPORATION 1988 .e: 4/25/2006 Timer 12:47 PM To: JANELL HANSEN ~ 9,12083593024 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. 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