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Home My WebLink AboutALL DOCS - 08-00307 - 4th of July Fireworks ShowRexburg Madison County Emergency Services 19 East Main St janellh @rexburg.org Phone: 208.359.3020x326 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 BV q 1 ; ^^ .d U'� C C I T Y OF REX Ob America's Family Community «OPERATIONAL PERMIT" APPLICATION PERMIT #: b $ bo ,O- 77 $50.00 FEE PAID: Y N PERMIT APPROVED: l YES/NO B ATE off — Owner: Phone Number: Owner Mailing Address: Property Address: Cell/Office Number: Business Name Where Work Will Be Done: Office Address: Office Phone Number: Applicant Information: VV PXV- r'C4 Contact Phone #: Name: L") ; WE Name of Business: �^`tZ f ir1 /� , .s LU Address: � /V• rt� (. i.� ��X� \fit 11 ' y 3 L Contact Person: �&FF fk,JtUI E PHONE NUMBER: 3S CELL # YL3'31S6 Parade Route /Assembly Location: (Map required for Parades) SCHEDULE: TO TIME • ` 1� , f P&I Si4wj Wt LL 13 (: Sr & F_A1 746 b7Y RW U Lt6e,S Pt mtX Contact Person: Applicant' nature D e • . PLEASE CHECKTHE TYPE OF PERMIT(S) YOU ARE APPLYING FOR: ❑ Aerosol product manufacturing List of contents: ❑ Combustible dust - producing operations Location: - Type of dust: ❑ Covered mall buildings Location: ❑ Cryogenic fluids Types: ❑ Cutting and welding operations Location: ❑ Dry Cleaning plants Location: Types of Chemicals: ❑ Exhibits and trade shows Location: Type of Fire Extinguishers & Location: Explosives Location: B� acs i4 WsW1t3t`� r Types: G v_* 5 ❑ Fire hydrants and valves Locations: Types: ❑ Flammable and combustible liquids Types: ❑ Floor finishing Types: ❑ Fruit and crop ripening Locations: Types: ❑ Fumigation and thermal insecticidal fogging Locations: Types: ❑ Hazardous materials Locations: Types: iy ❑ High -piled storage Location: Contents: ❑ Hot work operations Location: Dates & Times of Operation: ❑ HPM facilities Location: ❑ Industrial ovens Location: Types: ❑ Large capacity battery systems Location: Type: ❑ Liquid /gas vehicles /equip. in assembly buildings Location: Type: ❑ LP gas transportation Location: Type: ❑ Lumber yards /plants Location: ❑ Magnesium work Location: ❑ Misc. combustible storage Location: Type: ❑ Open burning Location: Time & Date: ❑ Operating amusement buildings Location: ❑ Operating aviation facilities Location: ❑ Operating carnivals or fairs Location: Dates & Times: ❑ Organic coatings Types: • ❑ Places of assembly Location: Dates & Times: ❑ Private fire hydrants Location: ❑ Pyroxylin plastics Types: ❑ Refrigeration equipment Types: ❑ Repair garages /motor fuel dispensing Location: ❑ Rooftop heliports Location: ❑ Spraying or dipping Location: U ❑ Storage of combustible fibers Location: Types: ❑ Storage of scrap tires /etc. Location: ❑ Temp. membrane structures, tents, and canopies Location: Date & Times: ❑ Tire - rebuilding plants Location: ❑ Use /Storage of compressed gases Location: Types: ❑ Waste handling Types: ❑ Wood products Types: Additional Information: 1 7 U ( p -3- JUN -27 -2008 FRI 12:12 PM Egan Metcalf & Leavitt FAX N0, 2085228049 P. 03 rnV#CD A r_r0 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INOICATED. 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 15 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR kbDl TYPE O F INSUR POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LE LIMITS - GCNERAL LIABILITY 72LPS005394 06/05/2008 06/OS/2009 EACH OCCURRENCE s f, 000 00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100. CLAIMS MADE D OCCUR MED EXP (Any one pere0n) S 5 . 00 01 A PERSONALS ADV INJURY $ 1.000, 00 GENERAL AGGREGATE S 2 000, 00 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMPIOP AGO i EXCLUDE POLICY JZ-c'r L.00 AUTOMOBILE LIABILITY COMBINED SINGL LIMIT S ANY AUTO (Es acodenl) BODILY INJURY S ALL OWNCO AUTOS SCHEDULED AUTOS (Per pereon) BODILY INJURY S HIRED AUTOS NON -OWNED AUTOS (Per accid°nl) PROPERTY DAMAGE S (PM accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT E OTHER THAN EA ACC S ANY AUTO $ AUTO ONLY: AGG EXCESS/UMBRELLALIABILITY XLS-- 0045956 06/05/2008 06/05/2009 EACH OCCURRENCE S 2 OCCUR ❑ CLAIMS MADE AGGREGATE S B 000000 B 2,000,00 I DEDUCTIBLE S RETENTION S WORKERS COMPENSATION AND YYC $TATU. OTM EMPLOYERS' LIABILITY E.L. EACH ACCIDENT S ANY PROPRIETORIPARTNERIEXECUTIVE E.L. DISEASE - EA EMPLOY S OFFICERIMEMBER EXCLUDED? If xCS, de.cribe under SI ECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT 5 OTHER DESCRIPTION OF OPERA �I ONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORS I SPEcIALPROVISIONS rfTCate Holder & Madison County is listed as addi insured nsured in regards to the insureds t� perations. Rexburg Chamber of Commerce 420 W. 4th South Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION GATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL 30 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 INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 3a_ i me_ Bradley ACORD 25 (2001108) FAX: (208)356 -3022 OACORD CORPORATION 1988