HomeMy WebLinkAboutAPPLICATION - 07-00087 - Nelson Fire Systems - Fire Safety CertificationO� g6XB URC
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BUILDING SAFETY DEPARTMENT
19 E. Main St.
Rexburg, Idaho 83440
www.rexburg.org
Phone: 208- 359 -3020 x326
Fax: 208-359-3024
janellh @rexburg.org
"SAFETY SYSTEM PERMIT #:
CERTIFICATION PERMIT" $100 Fee Pai Ye /No Permit Approved: Yes /No
APPLICATION
BY: Date:
"A safety gstem 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 systems within the City of
Rexburg"
BUSINESS NAME:
OFFICE ADDRESS: L� �' M4)d r S T r ee� �a l 1 �4 �e �y (AT $ ( 10 5
OFFICE PHONE NUMBER: 8 '1 60 - 6 300
CONTACT PERSON: 8 e g /V e` 5 01, CELL PHONE #: U G (� 5 2 - 7 I
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
6 et ' tifications.
*:•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,
LL4BILITYINSURANCE, ETC. FOR ALL DISIPLINES * **
�l (,, is
BUSINESS NAME. �' `� h � s \v 5 T �"'� S
PLEASE LIST ALL COMPANIES YOUR BUSSINESS IS AUT HORIZED TO REPRESENT:
COMPANY NAME: 6" e-J O /� ' � c- 6k4/'O Li 5 J PHONE #: 6 C O
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 signed above and am acting with the owner's /contractor's full knowledge or consent.
/5e h /V /so I
PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE
DATE PERMIT VALID UNTIL DECEMBER 31, 2007
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