HomeMy WebLinkAboutALL DOCS - 08-00020 - BYUI - Fire Safety Certification0
Rexburg - Madison County
Emergency Services
19 East Main St lanellh@rexburg.org Phone: 208.359.3020026
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024
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REXBURG
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.America;< Family Coinmunity
SAFETY SYSTEM CERTIFICATION PERMIT APPLICATION
PERMIT #:
$100 Fee Paid: es No Permit Approved• No
BY: Date:
"A safety system certification permit is required to install, modij, maintain, or seroice all new and existing fire
extinguishers, fire suppression systems, fire alarm systems, and other life safety systems within the City of Rexburg"
BUSINESS NAME: 41 u Zd4 ko Parcel:
OFFICE ADDRESS: 3
3 yjC d -
F
OFFICE PHONE NUMBER: . y94 -
CONTACT PERSON: Am h 1e,5w4USSzv1 CELL PHONE #: ;- 07 - ZO / - 97 7/
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
*: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
X FIRE EXTINGUISHERS STANDPIPE SYSTEMS
SMOKE CONTROL SYSTEMS FIRE PUMPS
SPECIAL HAZARD SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
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** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITYINSURANCE, ETC. FOR ALL
DISIPLINES * **
BUSINESS NAME: -�y a - Q �o
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANY NAME: 2y a - �.� o PHONE #: / 96 ;Za/ 0l
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 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.
A le tit 6t/ • QS'µ u 5s -e- L t
PAINT NAME OF APPLICANT
� �PLICAN�T'SGNATURE
/ -R- oe
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
-2-
SAFETY
SYSTEM
35.8
Rigby
Hall
CERTIFICATION
BYU
-Idaho
35.8
Rigby
Hall
Rexburg, Idaho 83460 -4530
PTRMIT# 08 00020
2008
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REXB
SIGNATURE
Americas Family Community
U /d
VALID THROUGH DECEMBER 31, 2008