HomeMy WebLinkAboutAPPLICATION - 05-00212 - BYUI - Fire Safety Certification~-
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flt4`1FRICA'S Frl~rill~Y CQYSR~tUi~;tTY
19 E. Main St.
Rexburg, Idaho 83440
www.rexburg.org
Phone: 208-359-3020 x326
Fax: 208-359-3024
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"
BUSINESS NAME: ~ yG~ ~~~~ ~So .f~,,_; ,.., ! ~-~„~~i~ r Parcel: /~d/~L. ~/~~~
OFFICE ADDRESS: ~ ~ S- -~ f ,~ ~ ~ Viz.' ,,~`f .,i :'~L~ -' ~~2~'~-
OFFICE PHONE NUMBER: `/ff - ..~%~%
CONTACT PERSON: ~,~",+-~,,. „~~,+.~ CELL PHONE #!: ~1,~' `~:}.,:~~'
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THAT APPLY.
AFIRE 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
d•Any Additional Certifications
•Proof of Liability Insurance
FIRE EXTINGUISHERS
SPECIAL HAZARD SYSTEMS
STANDPIPE SYSTEMS
FIRE PUMPS
SMOKE CONTROL SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING
***PLEASE PROVIDE DOCUMENTATION OFTRAIN/NG LEVELS, INSTALLATION CERTIFICATIONS, LIABILITYINSURANCE, ETC.
FOR ALL DlS/PLINES. ***
•
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT;
COMPANY NAME: ~~y'Gt '.Lc~w•C~= PHONE #:
COMPANY NAME:
COMPANY NAME:
PHONE #:
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.
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PRINT NAME OF APPLICANT
DATE
~~
APPLICANT'S SIGNATU
PERMIT VALID FOR ONE YEAR FROM DATE
OF APPROVAL.
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