HomeMy WebLinkAboutAPPLICATION - 05-00073 - Gem State Fire Protection - Fire Safety Certification- ~ ~'~~, ~1TY ~JF
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~'48l~su~^a~ AMERICA'S FrW11LY GOMNtI.tNrrY 19 E. Main St. Phone: 208-359-3020 x326
Rexburg, Idaho 83440 Fax: 208-359-3024
www. rexburg.org cdd@rexburg.org
"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"
BUSIi~ESS idA141E: _ G ~ h'! ~T'/4 TC ~R C Yi2 OT~L'T70~y Parcel:
OFFICE ADDRESS: /ID,S.Z~~IJR Kdi4.0 ~.~0~4it0 ~A~ rDANO ~3y~~
OFFICE PHONE NUMBER: _ ~n08- .3a y- sa 3 ~
CONTACT PERSON: ~ G l~ ~ D 2GA/)CELL PHONE #:
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, LIABILITY-NSURANCE, ETC.
FOR ALL D/SIPL/NES.***
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~• BUSINESS NAME 6 / !V
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME:
COMPANY NAME:
PHONE #:
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
all city ordinances, adopted codes, and state laws relating to the installation, moc
hereby authorize representatives of this city to inspect any work for compliance
owner as signified above a am acting with the owner's (contractor's full kno
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NAM
nation contain d herein is correct and complete. I agree to comply with
service, and intenance of new and existing life safety systems. I
I am either th contractor responsible for the work, or I represent the
VALID FpR (ENE YEAR FROM DATE
OF APPRO L.