HomeMy WebLinkAboutAPPLICATION AND SAFTEY SYSTEM CERTIFICATION - 08-00029 - Omni Security Systems - Fire Safety Certificationr
19 East Main St
Rexburg, ID 83440
C l 1 1` Y O F
REX
America's Family Community
Rexburg- Madison County
Emergency Services
jonellh @rexburg.org Phone: 208.359.3020026
www.rexburg.org Fax: 208.359.3024
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SAFETY SYSTEM CERTIFICATION PERMIT APPLICATION
PERMIT # : v 0 vc
$100 Fee Pa* /No Permit
BY:
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"A safety gstem certification permit is required to install, modifii, maintain, or service all new and existing fire
extinguishers, fire suppression ystems, fire alarm systems, and other life safety ystems within the Ci y of Rexburg"
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BUSINESS NAME: O/Yl nt/ 566_UL t �V-r7_C- -?, ` /�C . Parcel:
P.0 36 X 30'� 1
OFFICE ADDRESS: 10 S' zoo ,J.
OFFICE PHONE NUMBER:
CONTACT PERSON:
`2 -- - 7 qS- I D2 -
CELL PHONE #: 39e) "q 13 1
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL
THAT APPLY.
X 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
FIRE EXTINGUISHERS STANDPIPE SYSTEMS
SMOKE CONTROL SYSTEMS FIRE PUMPS
SPECIAL HAZARD SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS F nMMFRCiA
COOKING D 9 LC U v9
JAN 1 5 2008
CITY OF REXBURG -
0 0
** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITYINSURANCE, ETC. FOR ALL
DISIPLINES * **
BUSINESS NAME: D M N I < {a U (L t
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANY NAME: M_DUNN W ALA PLO PHONE #: /,Y 1 �Co , P- 5 7 - 2 -
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.
PRINT NAME OF APPLICANT
-/0-
-
APPLICANT'S SIGNATURE
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
Wa
SAFETY
SYSTEM
CERTIFICATION
0
Omni Security Systems
3905 E 200 N
Rigby ID 83442
C PERMIT# 08 00029
• 2008
CiTY ::0F
R E XBURG
CII/ -
" SIGNATURE
America' Fatuity Community
\ /?,4/
DATE
VALID THROUGH DECEMBER 31, 2008
I