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HomeMy WebLinkAboutALL DOCS - 08-00002 - Fire Services of Idahoati �taxa� >�r, ar CITY F U G R V R Americas Family Community HE� "SAFETY SYSTEM CERTIFICATION PERMIT" 0 BUILDING SAFETY DEPARTMENT 19 E. Main St. Phone: 208 - 359 -3020 x326 Rexburg, Idaho 83440 Fax: 208 - 359 -3024 www.rexburo.org janellh @rexburg.org PERMIT #: E $100 Fee Paid Yes No Permit Approved ( Y. APPLICATION BY• Date: t ? 1g "A safety system certification permit is required to insta , mod, maintain, or service all new and existing fire extinguishers, fire suppression systems, fire alarm systems, and other life safety systems avithin the City of Rexburg" BUSINESS uto, OFFICE ADDRESS: r) ( lol 1)nje 6 MZ /<, OFFICE PHONE NUMBER: log 272 ;) 6 L I% CONTACT PERSON: w �7 - ` ° 'r'� CELL PHONE �a 6 #: 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 or equivalent. *PLEASE PROVIDE CERTIFICATIONS: *NICET Certification *Panel Certification A* Proof of Liability Insurance AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minimum of NICET Level III Certifications or equivalent. *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, LIABILITYINSURANCE, ETC. FOR ALL DISIPLINES* ** s ( (L� 4S 'BUSINESS NAME: PLEASE LIST ALL COMPANIES Y UR BUSSIN IS AUTHORIZED TO REPRESENT: ` r�- COMPANY NAME: ✓ �(� C� P� �''J PHONE #: / S�` 46 C� e COMPANY NAME: G ��� L) 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 fornmkliance poses. I am either the contractor responsible for the work, or I represent the or as signified above and am acting with the owner's / t 1 PRINT NAME 9F APPLICANT APP CANT'S or consent. DATE P MIT VALID UNTIL DECEMBER 31, 2007 SAFETY SYSTEM CERTIFICATION 40 Fire .Services of Idaho, 2601 Poleline Rd. Pocatello, Id. 83201 Inc. C PERMIT# 08 00002 2 00 8 3 l CITY OF REX BU R G " SIGNATURE America� Family Community 17/v8 VALID THROUGH DECEMBER 31, 2008 ACDR CERTIFICA OF LIABILITY INSURA E DATE 8' PRODUCER (208) 522 -7778 FAX (2 Castle Lake Insurance P.O. Box 2751 Idaho Falls, ID 83403 Bruce Wal dram THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Fire Services of Idaho, Inc. 2601 Pol el i ne Road Pocatello, ID 83201 INSURER A: Arch Insurance Company POLICY EFFECTIVE INSURER B: LIMITS INSURER C: INSURER D: MFGL065 52 502 INSURER E: 01/16/2009 COVERAGES 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 BEEN REDUCED BY PAID CLAIMS. INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MM/13138M LIMITS GENERAL LIABILITY MFGL065 52 502 01/16/2008 01/16/2009 EACH OCCURRENCE $ 1,000,000. X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,00 CLAIMS MADE r OCCUR MED EXP (Any one person) $ S,00 A PERSONAL & ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2.000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $ 2,000,00 X POLICY PRO JECT LOC AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ HIRED AUTOS NON -OWNED AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO $ AUTO ONLY: AGG EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FI CLAIMS MADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WC STATU- OTH- TORY LIMIT., ER EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? If yes, describe under - SPECIAL PROVISIONS below OTHER D nn i DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS JAN 1 6 2008 5,000 Per Occurrence Property Damage Deductible JIUI CITY OF REXBURO City of Rexburg Attn: Kathy Winters 19 E Main Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE I RER, ITS AGENT P NTATIVES. AUTHORIZED REPRESENTAT#7E Bruce Waldram ACORD 25 (2001108) © ACORD CORPORATION 1988 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)