HomeMy WebLinkAboutAPPLICATION - 07-00043 - Western Automatic Sprinkler - Fire Safety Certification��o��tEXBURC,� — •
CITY
90 T�j�VnTm(� BUILDING SAFETY DEPARTMENT
T l�li1\l� V 117
06% a' America's Family Community 19 E. Main St. Phone: 208 - 359 -3020 x326
"E° a Rexburg, Idaho 83440 Fax: 208-359-3024
www.rexburo.org janellh @rexburg.org
"SAFETY SYSTEM PERMIT #: 000
CERTIFICATION PERMIT" $100 F P aid• es o Permit Approved: Yes /No
APPLICATION ��
BY: Date:
"A safety system certification permit is required to install, mod , maintain, or service all new and existing
fire extinguishers, fire suppression systems, fire alarm systems, and other life safety gstems within the City of
Rexburg"
BUSINESS A.A.11AE:
WESTERN AUTOMATIC SPRINKLER Parcel:
OFFICE ADDRESS: 2510 SOUTH WEST TEMPLE SALT LAKE CITY, UTAH 84115
OFFICE PHONE NUMBER:
801 - 484 - 3531
CONTACT PERSON: BRUCE HAGEN
CELL PHONE #: 801- 808 -2011
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
XX AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minim of
NICET Lcvcl III Certifications.
❖PLEASE PROVIDE CERTIFICATIONS:
*: *NICET Certification
****Any Additional Certifications
****Proof of Liability Insurance
FIRE EXTINGUISHERS XX STANDPIPE SYSTEMS SMOKE CONTROL SYSTEMS
SPECIAL HAZARD SYSTEMS FIRE PUMPS
XX AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING
** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS,
LI BILITYINSURANCE, ETC. FOR ALL DISIPLINES * **
0
BUSINESS NAME: WESTERN AUTOMATIC SPRINKLER
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME:
COMPANY NAME:
COMPANY NAME:
PHONE #:
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 either the contract responsible for
the work, or I represent the owner as signed above and am acting with the owner's /contractor's full knowl a or consent.
BRUCE HAGEN
PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE
JANUARY 30, 2007
DATE PERMIT VALID UNTIL DECEMBER 31, 2007
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