HomeMy WebLinkAboutALL DOCS - 08-00059 - Nelson Fire Systems - Fire Saftety Certification•
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America's Family C:owmunity
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BUILDING SAFETY DEPARTMENT
19 E. Main St.
Rexburg, Idaho 83440
www.rexbura.oro
Phone: 208 -359 -3020 x328
Fax: 208 - 359 -3024
janellh @rexburg.org
"SAFETY SYSTEM PERMIT #:
CERTIFICATION PERMIT" $100 Fee Paid: es No Permit Approved Y /No
APPLICATION
BY: Date:. � D�
"A safely system certification penwit is required to install, mod , maintain, or service all new and existing
re extinguishers, fire suppression gstems, fire alarm systems, and other life safety systems within the City of
Rexburg"
BUSINESS NAME: R
' :iEry1f Parcel: _
OFFICE ADDRESS: / < J ( Al 4 I r i— e '
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OFFICE �HUtvr; Nt)MBE t: v r
CONTACT PERSON: 0 CELL PHONE #: _ 7 1 1
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 minim o±
i"�ICET Level 1 , 11 Certiz ca.tior ; .r
❖PLEASE PROVIDE CERTIFICATIONS:
•3NICET Certification
❖Any Additional Certifications
*:'Proof of Liability Insurance
FIRE EXTINGUISHERS STANDPIPE SYSTEMS SMOKE CONTROL SYSTEMS
SPECIAL HAZARD SYSTEMS FIRE PUMPS
AUTOMATIC FIRE EXTINGLi SHING SYSTEMS FOR COMMERCIAL COOKING
** *PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS,
LIABILITYINSURANCE, ETC. FOR ALL DISIPLINES * **
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BUSINESS NAME: / =''i , i S ,s �e &
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME: G
PHONE
COMPANY NAME:
COMPANY NAME:
PHONE #:
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 signed above and am acting with the owner's /contractor's 11 knowledge or consent.
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PRINT NAME C_1F .,N-PPLICANT .''APPLICANT'S SIGNATURE
DATE PERMIT VALID UNTIL DECEMBER 31, 2007
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Nelson Fire Systems
1481 Major Street
Salt Lake City UT 84115
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PERM
SIX Bv
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IT# 08 00059
2008
CITY O F
REXBURG I /
I - C �W - SIGNATURE DATE
Americas Fam Community
VALID THROUGH DECEMBER 31, 2008