HomeMy WebLinkAboutALL DOCS - 08-00067 - Shilo Automatic Sprinklers Inc - Fire Safety Certification0
C I T Y OF
REX
America's Family Community
4 0
BUILDING SAFETY DEPARTMENT
19 E. Main St.
Rexburg, Idaho 83440
www.rexburg.org
Phone: 208 - 359 -3020 x326
Fax: 208 - 359 -3024
janellh @rexburg.org
"SAFETY SYSTEM PERMIT #: l
CERTIFICATION PERMIT" $100 Fee Paid: a /No Permit Approve�No
APPLICATION
BY. Date: l3
"A safety system certification permit is required to install, mod , maintain, or service all new and existing
fire extinguishers, fire suppression systems, fire alarm systems, and other life safety systems within the City of
Rexburg"
� SS NAME- BUSIN ��A A /� n
N�U�T 4C /'�����KP
OFFICE ADDRESS: I X;& ELF—VE M rp( A1/a NLYZr g, A)Ay pA , T:D �31o
OFFICE PHONE NUMBER: �0 �" q&& " 000 Le
CONTACT PERSON: CELL PHONE #:
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
ICET 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,
LL4BILITYINSURANCE, ETC. FOR ALL DISIPLINES * **
BUSINESS
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAM da - ��Cl l� PHONE #:
COMPANY NAME: « �' - y�Yy 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 ntra is full knowledge or consent.
PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE
- z- — /i v �s
DATE PERMIT VALID UNTIL DECEMBER 31, 2007
• •
SAFETY
SYSTEM
CERTIFICATION
0
Shilo Automatic Sprinkler Inc.
1224 Eleventh Avenue. North
Nampa ID 83687
C PERMIT# 08 00087
• 2008
CITY OF
REXBUR
SIGNATURE
.Americra� Family Community
46 I -
DATE
VALID THROUGH DECEMBER 31, 2008