HomeMy WebLinkAboutAPPLICATION - 07-00128 - A & S Electric - Fire Safety CertificationO
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C I T Y O F
REXBURG
:1 itleriut:c t Curr�muxity
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BUILDING SAFETY DEPARTMENT
19 E. Main St.
Rexburg, Idaho 83440
www.rexburci.org
Phone: 208-359-3020 x326
Fax: 208-359-3024
janellh @rexburg.org
"SAFETY SYSTEM
CERTIFICATION PERMIT"
APPLICATION
PERMIT #:
$100 Fee Pai Ye f No Permit Approved: Yes o
BY: o Date: °
"A safety ystem certification permit is required to install, mod f, maintain, or seruice all new and existing
fire extinguishers, fire suppression systems, fire alarm systems, and other life safety ystems within the City of
Rexburg"
BUSINESS NAME:
A ; 3 V_ C t L Parcel:
OFFICE ADDRESS: 3!3o No4k mGr✓ y_as -- ��Li�_W S 2-
OFFICE PHONE NUMBER: (Z 03) 7-4 �> - 0 z sn
CONTACT PERSON: 5A Avudtd'Sc_r CELL PHONE #: C 75,E Z`-I - Zs y
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THAT
APPLY.
r/ 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 S YSTEMS
SPECIAL HAZARD SYSTEMS FIRE PUMPS
j FM AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMAqQO9M9T"'V
** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INST T1fON CERTIF �+
LIABILITYINSURANCE, ETC FOR ALL DISIPLIN * *, CITY OF S t 1
•
0
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME: 6 ` L i �t PHONE #: C Lo35 l
COMPANY NAME: F 1 f S � & I tA 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 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.
F—Aw ►lkyvi rr-" eA
PRINT NAME OF APPLICANT
31 tt�/ Q'1
APPLICANT'S SIGNATURE
DATE PERMIT VALID UNTIL DECEMBER 31, 2007
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