HomeMy WebLinkAboutAPPLICATION & PERMIT - 07-00052 - Gem State Fire Protection - Fire Safety CertificationO4 gEXB UR
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BUILDING SAFETY DEPARTMENT
19 E. Main St.
Rexburg, Idaho 83440
www.rexbur4.org
Phone: 208-359-3020 x326
Fax: 208 - 359 -3024
janellh @rexburg.org
"SAFETY SYSTEM PERMIT #:
CERTIFICATION PERMIT" $100 Fee Paid:
APPLICATION
o Permit Approved: Yes /No
BY: Date:
"A safety system certification permit is required to install, mod , maintain, or service all new and existing
fire extinguishers, fire suppression ystems, fire alarm systems, and other life safety ystems within the City of
Rexburg"
BUSIINES NAME-
6 (f fn Tire Fi e &,07 - e TtOo Parcel:
OFFICE ADDRESS: II Dff A) A A 4 � 1 �- S x z al
OFFICE PHONE NUMBER:
CONTACT PERSON Joe t' 1 o 2 6 6 N 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:
4 *NICET Certification
*Panel Certification
** 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 K FIRE PUMPS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING
** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS,
LL4BILITYINSURANCE, ETC. FOR ALL DISIPLINES * **
BUSINESS NAME: �CI'I1 Tl9T� j,V e P!?07
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME:
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
comply with all city ordinances, adopted codes, and state laws relating to the
life safety systems. I hereby authorize representatives of this city to inspect
the work, or I represent the owner as signified above and am acting with t e �
PRI T AME OF APPLICANT A
O
DA E
I n
information contained herein is correct and complete. I agree to
tion, modificati ,service, and maintenance of new and existing
for complian urposes. I am either the contractor responsible for
/ cAtractor' ll knowledge or consent.
VALID UNTIL DECEMBER 31, 2007
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