HomeMy WebLinkAboutAPPLICATION - 05-00147 - BYUI Safety Office - Fire Extinguishers~~~b,~ CITY CJF
`~.q$~~N~1'~ AMERICA'S FAMILY COMMLINtTY 19 E. Main
Rexburg, Ic
www. rexbu
05 00147
BYU! Fire Extinguishers
"SAFETY SYSTEM PERMIT#:
CERTIFICATION PERMIT" $100 Fee Paid: Yes/No Permit Approved: Yes/No
APPLICATION
BY: ~'-- Date: ~ ~~~~•~
"A safety system 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:
OFFICE ADDRESS: TFD ~~~9 bbl,. ~ ~ ~ ~ ~~o
OFFICE PHONE NUMBER: ~'GI6 ~ ~~8
CONTACT PERSON: ~• ~~~~ llG~tllCELL PHONE #: 3~~'.33 g
PL DENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THAT APPLY.
~`(, IRE ALARM SYSTEMS -Alarm Contractors shall have a minimum of NICET Level 1 Certifications
C~'' •PLEASE PROVIDE CERTIFICATIONS:
•NICET Certification
•Panel Certification
•Proof of Liability Insurance
~ as p.~z N~'PA~ ~z
,, AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minimum of NICET Level III
Certifications.
•PLEASE PROVIDE CERTIFICATIONS:
•NICET Certification
•Any Additional Certifications
roof of Liability Insurance
FIRE EXTINGUISHERS TANDPIPE 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 D/SIPLINES.***
BUSINESS NAME: Q, ~~~.Z
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME: ~~~'~(~Q~ PHONE #: ~~~ -~~~
COMPANY NAME:
PHONE #:
COMPANY NAME: PHONE #:
*****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 of this 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.
~yle. (2. ~~ ~~~,an~S
PRIN ~ MEN f~~ LICANT
APP ANT'S SIGNATURE
DATE PERMIT VALID FOR ONE YEAR FROM DATE
OF APPROVAL.