HomeMy WebLinkAboutAPPLICATION - 08-00346 - International Folk Dance Festival - Fire PermitRexbu g- Madison County �� f V- XBt1j,Q, C 1 T Y O 1:
Emergency Services
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19 East Main St ionellh @rexburg.org Phone: 208.359.3020x326 cla.
Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3024 America's Family Community
, �OPERAI'IONAL PERMIT" APPLICATION
PERMIT #: l 00
\ $50.00 FEE PAII)k YES NO PERMIT APPROVED: YES /NO
Owner Information Parcel Number:
Owner v�.�,..r,, ��� f ���;; 1 ,,,,, : - Phone Number:
Owner Mailing
Property Address: - Cell /Office Number:
Business Name Where Work Will Be Done:
Office Address:
Office Phone Number:
Contact person: F�, . -u._ G=v;. :, (,` Contact Phone #:
Applicant Information:
Name: Q
Name of Business: L. / 1 ? ql�ZWT�y l� LL
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Contact Person: PHONE NUMBER: cJ/ TC./ CELL #
Parade Route /Assembly Location:
(Map required for Parades)
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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:
Types:
❑ Fire hydrants and valves
Locations:
Types:
❑ Flammable and combustible liquids
Types:
❑ Floor finishing
Types:
❑ Fruit and crop ripening
Locations:
T es:
❑ Fumigation and thermal insecticidal
fogging
Locations:
Types:
❑ Hazardous materials
Locations:
. Types:
❑ 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:
Addifinnal Infnrmafinn-
•
❑ 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:
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ACO T CERTIFIC E OF LIABILITY
INSURIok''�CE 07/14/2008
THIS CERTIFICATE IS'oSSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER (208) 524 -5858 FAX (208)522 -8049
Egan, Metcalf & Leavitt
3780 N. Yellowstone
PO Box 2498
Idaho Falls, ID 83403
INSURERS AFFORDING COVERAGE
NAIC #
INSURED Elite Pyrotechnics, LLC
217 N 3rd West
Rexburg, ID 83440
INSURER& National Fire & Marine
20079
INsURERB: Scottsdale Insurance Company
41297
INSURER C:
$ 1,000,00
INSURER D:
OAMAGE TO RENTED
INSURER E:
CLAIMS MADE a OCCUR
CY]VFIZCC:FC
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS
OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BYU Idaho
INSR DD' TYPE OF INSURANCE POLICY POLICYEFFECTIVE POLICYEXPIRATION
1
LIMITS
GENERAL LIABILITY 72LPS005384 06/05/2008 06/05/2009
EACH OCCURRENCE
$ 1,000,00
X COMMERCIAL GENERAL LIABILITY
OAMAGE TO RENTED
$ 100
CLAIMS MADE a OCCUR
MED EXP (Any one person)
$ 5,00
A
PERSONAL & ADV INJURY
$ 1,000,00
GENERAL AGGREGATE
$ 2
GENL AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$ EXCLUDE
POLICY PR
T LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$
ANY AUTO
(Ea accident)
ALL OWNED AUTOS
BODILY INJURY
$
SCHEDULED AUTOS
(Per person)
HIRED AUTOS
BODILY INJURY
$
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE
$
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
ANY AUTO
OTHER THAN EA ACC
$
AUTO ONLY: AGG
$
EXCESSIUMBRELLA LIABILITY
XLS- 0045956
06/05/2008
06/05/2009
EACH OCCURRENCE
$ 2 , 000,00
OCCUR ❑ CLAIMS MADE
AGGREGATE
$
B
2000000
$ 2,000,00
DEDUCTIBLE
RETENTION $
$
WORKERS COMPENSATION AND
WC STATU- OTH-
EMPLOYERS' LIABILITY
IQEY L WITS ER
E.L. EACH ACCIDENT
$
ANY PROPRIETORlPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYE
$
If yes, describe under
E.L. DISEASE - POLICY LIMIT
1 $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
he above listed names are listed as additional insureds in regards to the insureds operations.
CERTIFICATF WnI IIQD nw 1 -t t
AcvRO 25 (2001108) OACORD CORPORATION 1989
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
International Folk Dance Festival
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Rexburg Chamber of Commerce
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BYU Idaho
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
City of Rexburg
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Rexburg ID 83440
AUTHORIZED REPRESENTATIVE f1
[ Jaime
Bradle JB
AcvRO 25 (2001108) OACORD CORPORATION 1989