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Home My WebLink AboutAPPLICATION & ALL DOCS - 07-00238 - BYUI - Torch ParadeRexbur - Madison County x8`1R.. CITY a F Emergency Services s RE 19 East Main St joneiih@rexburg.org Phone: 208.359.3020x326 ' cv. Rexburg, ID 83440 www.rexburg.org Fox: 208.359.3024 Americas Family Cmntuunity «OPERATIONAL PERMIT" APPLICATION PERMIT #: 01 DQ3 ! $50.00 FEE PAID YES/ O PERMIT APPROVED: YES /NO BY: DATE: G' G " f Z Owner Information Parcel Number: 1 Owner �t ! ��,' Phone Number: Owner Mailing Address: S ( n't� 6 / G� ► �� 7 t� Property Address:. Cell /Office Number: Business Name Where Work Will Be Office Address: Office Phone Number: Contact Person: Applicant Information: Contact Phone #: Name: � A I r N -, Y) ckv,l ' Name of Business: ?D"4 0 - k cA a J "\_-,= Address: sa s S C -,, k- ti [ _ <" V 1 ) -� Contact Person: 9fif,, f)c;-- V , 'K PHONE NUMBER: G ) __ & � 4 CELL # 9 01 - &?�a Le r— Parade Route /Assembly Location: (Map required for Parades) C '7 Applicant's Signature �` Date ! 0 PLEASE CHECKTHE TYPE OF PERMIT(S) YOU ARE APPLYING FOR: ❑ Aerosol product manufacturing List of contents: ❑ Combustible dust - producing operations Location: Type of dust: ❑ Covered mall buildings Location: ❑ Cryogenic fluids Types: ❑ Cutting and welding operations Location: ❑ Dry Cleaning plants Location: Types of Chemicals: ❑ Exhibits and trade shows Location: Type of Fire Extinguishers & Location: ❑ Explosives Location: Types: ❑ Fire hydrants and valves Locations: Types: ❑ Flammable and combustible liquids Types: ❑ Floor finishing Types: ❑ Fruit and crop ripening Locations: Types: ❑ Fumigation and thermal insecticidal fogging Locations: Types: ❑ Hazardous materials Locations: Types: ❑ High -piled storage Location: Contents: ❑ Hot work operations Location: Dates & Times of Operation: ❑ HPM facilities Location: ❑ Industrial ovens Location: Types: ❑ Large capacity battery systems Location: Type: ❑ Liquid /gas vehicles /equip. in assembly buildings Location: Type: ❑ LP gas transportation Location: Type: ❑ Lumber yards /plants Location: ❑ Magnesium work Location: ❑ Misc. combustible storage Location: Type: ❑ Open burning Location: Time & Date: ❑ Open flames /torches Location: Time & Date: ❑ Operating amusement buildings Location: ❑ Operating aviation facilities Location: ❑ Operating carnivals or fairs Location: Dates & Times: ❑ Organic coatings Types: • ❑ Places of assembly Location: Dates & Times: ❑ Private fire hydrants Location: Pyrotechnic special effects material (Fire works) Location: X4,1 +— Ke.ta) �rt l -i Types: ❑ Pyroxylin plastics Types: ❑ Refrigeration equipment Types: ❑ Repair garages /motor fuel dispensing Location: ❑ Rooftop heliports Location: Additional Information: • ❑ Spraying or dipping Location: ❑ Storage of combustible fibers Location: Types: ❑ Storage of scrap tires /etc. Location: ❑ Temp. membrane structures, tents, and canopies Location: Date & Times: ❑ Tire - rebuilding plants Location: ❑ Use /Storage of compressed gases Location: Types: ❑ Waste handling Types: ❑ Wood products Types: IBM doll V40 - ��k 0 � BYU -IDAHO EMERGENCY PHONE & AED LOCATION MAP Campus police 496 -3000 -- "'-� ' '`,� ��- Emergency ,.A.. ® -'-` Phone 7 �L If calling from campus phone 911 If using cell phone call 496 -3000 J Automated When the call is made campus police will 1`�'� External come to help in the emergency. [ Deflbrlltators Give EMS dispatcher the following info. • Location • Building or field location - • Where is the injured person located at? { • Telephone number or location from where the call is being made. , • Caller's name y • What happened A . L • How many persons injured • Condition of victim(s) • Help (first aid) being given, _' � Injury report needs to be games management. J ESF East Soccer Field BBD Baseball Diamond LNF Lower North Field WSF—�, West Soccer Field LEF Lower East Field LWF Lower West Field New 4 -plea y the -_ 1 0 j C t. 4 4 - L F-t r ir $ t Sports Medicine Room Hart 169B Phone: 496 -2109 Cell: 709 -6421 EUP East Upper Field SUP South Upper Field UPF Includes EUP & SUP 13 • 0 AC CERTIFICATE OF L IABILITY INSURANCE 06/05200? (208) 524- SS8 FAX (2W)S22-9K9 Egan , Metcalf B Leavitt 3y80 N. Yel lawlatonat THIS CERTIFICATE IB ISSUED A$ A_ MTER OF IMFORMAY10N ONLY AND CONFERS NO RIGHTS UPM THE CER7IRCATE ER TI,1IS CERTMICATE DOES NOT AMIEI11, EXTEND OR AL THE CO E WORDED BY THE POLICIES BELOW, PO Box 2498 IdaM Fal l s, ID SS400 I NSURBR8 AFFORDING COVERAGE NAIL N � In ite rot cs, Luc INSam A. National Fire 3 Marine 20079 217 N 3rd West INb>m s Scottsdale Insurance Company 41297 Rexburg, 10 23440 INSURER C s 1 INQIRER b' Xj WORPOA,L GENERK, 41 AO L17Y E2 Colas MAX fT OC" INSURER E: THE P"IFA OF WSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MWE FOR THE POLICY PERIOD INDICATED. NOTWIIHSTANDRIO ANY REDI/IREMENT, TERM OR COWITION OF ANY CONTRACT OR OTHER DOCUMENTVWTH RESPECT TO WAIN THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAJN, 711E 813lJRAWCF AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUB.IECT TO ALL THE TERM, EXCLUSIONS AND CONWTIONS OF SUCH POLIIhE3. At3I3RE0ATE LIMITS S K MYN MAY WAVE BEEN REDUCED BY PAID CLAIMS. TV" OF r6URAMCE PGIJGY um" OGaIAILJAaIILM 72LPSM1171 06/05/2007 06/05/2008 EACH E s 1 Xj WORPOA,L GENERK, 41 AO L17Y E2 Colas MAX fT OC" s 100 NO EXP ( Am olw pwTa�l i � A PERSV OL IN.k1RY a 1 GHHMALAGATE $ 2.000 C L, A.IIT APPLIES PER COLI Y P P " T r7 LOC PRODUCM - COAPIOP AGG S EWL AL110 WI AL Ae1L11Y MY AUTG„ COMBm BN�I l:4/YiT (Ea ewcltlwltj a ALL OWWDAUTOS SO4LULEDA OS 9b0'LY MARY (Pw'Pwwj a HIRED NJT06 NON -OYOED AUTOS oObIY INAXLY IPer ecclowtl a PROPE" DANt4GE rPer ax+awt} a - — UAW L AwRY NFO ONLY - EA ACCIDENT s /Wr AUY OTHER now EA ACC S Auro only: pal a CICMpRAIlRaLALYIlam X WZUR F CLAW MADE TBD 06/ 05 /2007 06/05/2008 EAcHoo E ASGREGATF $ 2 , 000 , a e 2000000 $ 2.000 a OEOLC.TWLE•: x aCrEVrlav a 10, ON a MImtmu comm ~=" eNr nwovs A jWX LHmLITY ANY PROPRETDILPARRWRe)(ECLITIVE OFFICEPUMEMBER FXCLLCE17T r B9&AL PAOMAS* q Wk- RL. EA04 ACCIDENT S E.L. DISEASE - EA EMPLOYEE9; F L,DILILA0i , POLICY ( a o7NaR � ff @CIWrWN qP 2 [107r97oa1tloweIvEfNCLesrExcLLI Aot�erEIOaRee +errIsFecruFleovlMlonY BYU Idaho Attn. Trent 525 S. Center Rexburg, ID 83460 AcwD m moim FAX: ( SHOO .D ANY OF T?e AW46 C5WOM) PGLICU N CANCIL M I WKw rr A if l wpAllON CATS 7FL�60F, TFE My111NG INSIAAER VNLL DMAVOR TO MW omm mwirrBI man= m TIE cmIrw Alm HouO NhwD To TIE LEFT, WJT FAILUM 70 Oft SUCH 00910E WOU WM NO OKJGA71Dn f= LJMS,rtY OF AMY mm UPON T►! S rim rrs Amm A TM-ft im,t9 -'n IN GK. ?61617 TGI 1 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A stalement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 4 SUBROGATION IS WAIVEO, subject ton the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s), DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively ah+end, extend or after the coverage afforded by the policies listed thereon. ACORD 25 (2001109) ACORP. CERTIFICA OF LIABILITY INSURA DA TE 5/ 29/2007 INSR ADD1 TYPE OF INSURANCE POLICY NUMBER PRODUCER (208)524-5858 FAX 'V8) S22 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Egan, Metcalf & Leavitt ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 72LPS001171 05/30/2006 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3780 N. Yellowstone $ 1,000 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 2498 Idaho Falls, ID 83403 $ 100,0 INSURERS AFFORDING COVERAGE NAIL # INSURED Elite Pyrotechnics, LLC INSURERA. National Fire & Marine 20079 217 N 3rd West $ , INSURER B Rexburg, ID 83440 INSURER PERSONAL & ADV INJURY $ INSURER D. e INSURER E: _ ^� /+A\!Cft A#--0& THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE B EEN REDUCED BY PAID CLAIMS. INSR ADD1 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LISTS AUT4ORIZEDREPRESI3YTATIVE GENERAL LIABILITY 72LPS001171 05/30/2006 05/30/2007 EACH OCCURRENCE $ 1,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEp $ 100,0 CLAIMS MADE [ OCCUR MED EXP (Any one person) $ , A PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ AEX CLU MDE GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ POLICY PROT- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCE8SAJMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ W $ DEDUCTIBLE $ RETENTION $ WORKERS COMPffNBATION ANO WC " OTH- ER Y " EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECLMVE E.L. EACH ACCIDENT — — $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If y es, describe under SPEC IAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DE8CRIPTION OF OPERATE i LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS R E ! 6, 2007 Show he insured is in the process of renewing the above policy. Once the policy is renewed, a renewal c ertificate will be sent Imo!- `STI!'In ATL "^I - AAII^CI 1 ATM ►1 ACORD 23 (2001108) FAX: (208)496 -5888 MAACORD CORPORATION 1986 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE "a EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MM0. BYU Idaho DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED TO THE LEFT, Attn: Trent BUT FAILURE TO MAIL SUCH NOTICE SFWLL DOSE NO OBLIGATION OR LIABLITY 52S S. Center OF ANY KIND UPON THE IN SURER, ITS AGENTS OR REPRESENTATIVES. Rexburg, ID 83460 AUT4ORIZEDREPRESI3YTATIVE [ Jaime Bradle JB ACORD 23 (2001108) FAX: (208)496 -5888 MAACORD CORPORATION 1986 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)