HomeMy WebLinkAboutALL DOCS - 12-00002 - Christensen Fire Extinguisher Annual Certificationoo
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Rexburg -Mudison County
Emergency Services
Phone: 2483593A20x326
Fox:208.359.3024
jone/lh@rexburg.org
www.rexburg.org
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REXBURG
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PERMIT#' J4 -DnnnJ --
$100 Fee Paid(Ye#No Permit Approved: Yes/No
BY: Date:
",tl .ra1i1y ty$en certifimlnn pennit is ngnind to inilall, modfi, mainlnin, or senict all new und extstingJirv
exlinguithcn,frc :nppnssion ystems,Jirc alnnn tlstems, and otber liJi :qfefi ystens uithia tln Ciry oJ'I\exburX"
BUSINESSNAME: AHQr'fc .r,v loefu.-; 'gu,,.lr', la. Pucel:
OFFICE ADDRESS:'7,3 :1 F.'/A. ) ,, oe
OFFICE PHONE NUMBER ( ees\,.8),7 * J/ s 5*
CONTACT PERSON: ?nrf ('ft.,.r*nsoo CELL PHONE #/^ar) Bet - 6r/L
PLEASE IDENTIFY SYSTFMS TO BE COVERED BY THIS PERMIT. CHECK ALL
TH{T APPLY.
--FIRE AI-ARM SYSTAMS - :\lann Contrnctors rhall have a minirnunr of NIC['jf Level 1
Certifications or equivalent.
T.PLH,ASII PROVIDI.I CERI'I FICA IIONS:
{' NIC lj'f Ccrrificatir-rn
t Panel (lcrrihcatiort
{.Proof of l-inbiliw Insurancc
-AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a
minirnum of NIChT l-evel III Certifications or equivalent.
{. PI,F,AS H PROVIDE CT.iR'fI F ICA"TIONS:
{. N ICF:'| Ccrti fication
{. r\ny r\dditional CertiFrcn tions
{.Proof of Liabfity Insurance
FIRE EXTINGUISHERS
_sMoKE CONTROL SYSTEMS
-STANDPIPE SYSTEMS
'-FIRN PUMPS
--.-SPECIAL TIAZARI) SYSTSMS
_X-AUTOMATIC FIRE EXTTNGUTSHTNG SYSTEMS FOR COMMERCTAL
COOKING
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***PLEASE PROYIDE DOCAMENTATION OF TfrAINING I.EWLS,
TNSTALLATION CERTIFI CATIONS, LIA#ILTTY INSURANCE, ETC. FOR ALL
DISJPLINES***
PHONE #:
PHONE #:
COMPANY NAME: PHONE #: _**PLEASE LTST ADDITIONAL COMPANY AUTHORIZATIONS ON THE SACK OF
T:{IS FORM**
I ccrti$ that I hnve tead thie rrpplication and declare under pcnalty of periury that the information containedherein is conect and complete. I agtee to comply with all city odinances, aJopted codes, and state lawstelating to the installation, modification, service, and maintenance of ncw andexisting liie safety systems. Iheteby authoriue repres,entatives of this city to inrpect any work for complian". pr,.pol.r. I nm rither thecontractor reeponsible for the wotk, or I reprcsent the owner as signitied above and nm acdng with the ownerre/contractorts full knowtedge or consen:.
PRINT NAMA OF APTLICANT
tl/ 3 /?7 'z-2,, t t
DATA
PERMIT VALID UNTIL DECSMBER 31 OF THE CALENDAR YEAR AI'PLTED FOR.{r:l'*{'*****{t**{.{.*!k{.{.{$4.**{.***{.{.**l.r}!t **r}{.{r***************4.*********{.r1.:1.+rl$irr*,ftrl.rt,t t***
BUS:NE$$ NAMEr C Xes'rcrs =.,
PLEA$E LIST ALL COMPANIES YOUR BUSINESS IS AUTHORTZED TOREPRESENT:
COMPANY NAME:
COMPANY NAME:
APPLICANT'S SIGNATUR5
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cERrFrc?rE oFLrABrLrry fNsrfr"=THIS CERTIFICAEIScERnFrcArE DoEs NorAFnaunnvilvt'mtqrysr!oiittq'#Er'ot-9111ei TiiE';bi/-Ei,;tEAFF.RDED By rHE porcrEsBELow' rHrs cERnFrcA1191$uhnricEb'ii;no-r corviniiftii
"-6'rirnn"r eErwiEN iHE',Gr,ru rNsuRER(s), AUTH.RTZEDREPRESENTATTVE OR pRr rFrcATE noloen. .. __,.
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Big Sky Underwriters
A Division of Hull and Company rnc
P.O. Box 3567
Missoula MT 59g06
406-721-9311
Christensen Fire Extinguisher Co.
732 Falls Drive
ldaho Falls
Tr.{,s s;o .=*t'=|'??fT"?J;Ivltl"'+ttltx'-F.i"'lnsll;:[Wie$rl+i#i]U+-'"":+:*l'sl,1tffiFx"u+s,.;BT.,,.f,pTl#{'"
Y PAID CLAIMS.
IAL GENERAL LIABILITY
cLArkrs-r,,rADE lTl o..r*
AUTOMOBILE LIABILITY
ANY AUTO
fj_,f9$4,JED f_lscseour-roAuros l_l Aurori".-"
HTFFDAUT.. Ll l3l;o.*=o
BOOItY tNJJRy (per peGon)
BODILY tNJURy (per
UMBRELLA LIAB
EXCESS LIAB
ANO EMPLOYERS' LIABILIry
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DEs cRt pl oN oF openen or,r JrEdfrffi r^iac- A;ORA tOr, ooo,tF Tarks schedute, ir'no."
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City of Rexburg
35N1stE
Rexburg tD g3441
SHOULD ANY OF THE ABOVE DE-SCRIBED POLICIES BE CANCELLED BEFORETlrE EXprRAroN DArE THEREoF, norce wr_l-ii-#iii=*.o,"AccoRDANcE wrrH THE polrcy pRovrsrolr-s. -- ---'',
ACORD 25 (211Dto5l The ACoRD name and roso are resistered,"r:.It^t;llt n@ reserved.
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Development
O *".",0, Number: 1?{!02-.ig;,.:l
tD. 83440
(208) 35e-3022
evious Payment History
Fee Descrlptlon Permlt #
$ 100.00
I JANO I2OII
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