HomeMy WebLinkAboutALL DOCS - 13-00009 - 5383 S 1650 W - Firewise Annual Safety Certification35N IrE
Rexburg, lD 83440 www.rexburg.org
-Mqdison Counly
Emergency Services
Phone: 208.372.2341
Fox: 208.359.3022
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REXBI,IRG
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PERMIT#:
$100 Fee Paid: Yes/No Permit Approved: Yes/No
BY:Date:
"A tnrtry sltstem certfication permil is required lo install, modtj4 maintain, or seruice a// new and existingfre
extingaishers,fre suppression slstems,fre alarm slstems, and other hft tnrtU ystems within tbe Ciyt ofkexburg"
BUSINESS NAME: FtaIJW$v LL<- Parcel:
OFFICE ADDRESS, 6ag"t { . i aea 1A,,, P-:wx9u<ta I D %14io
oFFIcE PHoNENUMBER' 2og, 20 | " t zbL'
CONTACT PERSON: ir<srrl ktc*i<CELL PHONE #: 2D8 20 | to6 L
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
Certrfications or equivalent.
*PLEASE PROVIDE CE,RTIFICATIONS;
*NICET Certificauon
..!.Panel Certification
*Proof of LiabiJity Insurance
AUTOMATIC SPRINKLER SYSTEMS * Fire Spdnkler Conttactors shall have a
nunimum of NICET Level III Cerificarions or equivalent,
{. PLE,ASE PROVIDE CERTIFICATIONS:
{.NICET Certification
.f.Any Addiuonal Certifications
{.Proof of Liability Insurance
N FIRE EXTINGUISHERS
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
-SPECIAL HAZARD SYSTEMS
-FIRE PUMPS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
VZ_g,W t56
***PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITY INSUR'{NCE, ETC, FOR ALL
DISIPLINES*'td(
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANY NAME: F t oew t5€ L t' <-PHONE #, '2dfr )ai ta6?-
COMPANY NAME:
COMPANY NAME:
PHONE #:
PHONE #:
**PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF
THIS FORM**
I certi$ that I have read this application and declare undet penalty of periury that the information contained
herein is cortect and complete. I agree to comply with all city otdinances, adopted codes, and state laws
relating to the installation, modification, service, and maintenance of new and existing life safety systems. I
hereby authorize tepresentatives of this city to inspect any work for compliance purposes. I am eithet the
contractor responsible for the work, ot I reptesent the ownet as signified above and am acting with the ownefs
/contractor's full knowledge or consent.
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PRINT NAME OF APPLICANT
ttil7lry
DATE
PERMIT VAIID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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Hr5 SUHPLU5 Ltttts LUN tt{AU I t5 tSbubl)
URSUANTTO THE IDAHO INSURANCE LAWS
Y AN INSURER NOT LICENSED BY THE
)AHO DTPARTMENT OF INSURANCE.
HEffI IS NO COVERAGE PROVIDED FOR
URFLUS tINE INSURANCE SY EITHER THE
}AHO INSU RANCH GUAftANTY
,SSOCIATION OR BY THE IDAHO LIFE AND
ITALTI{ INSURANCE GUARANW
SSOC|AT|ON. Janet Beaver #BA1g86
cre&$ss$E ---*- Ml s4501pottcY PER|AD: Fromft-io;rbtl i;lffi-rflIo1r ai ti:tii A.M. $tandard tirno ai your mniling addroua shown above,
8u*inoss Desmiption: Fire Exfingulshsrs
Q IndMduot Q Jolnl Venluro Q Pe*nornhlp 0 L*mllgd Lirbility Cornpony (LtS) fi org*nizatlor {other thnn pa{ncrchip, LLc or Joint Vent,lra}
IN RETURN FOR THE PAYIITH}IT OF THE TREHIUII, AflN SUBJECT TO ALL TI{- TERilI$ OP THI$ POLICY, 1IYE AGREEUf:Tl{ You ro pRo$ulq rHF |lrtsuRAl{cE A$ srATgo }t{ TH!$ pcLtcy.THls PoLlcY coftl$lsTs oF THf FoLtowlHc coVESAcH PAiT$ rbii wHtcH A FREIntUtrf ts tilDlcATED. rHtsPREI$IUII I$AY BE SUBJECT TO ADJUSTTIIENT.
Ccmmerc:iel Genersl Liebility Cov*rage Fert
pREtiluM
$1,314.00
POLICY IIIO.: CCP 7$7667
NAMEP INSURED AND ADDRFS$:Firspriee LLC5383 S. 16$0 W
Rexburg ln
Policy Fes
lnopeclion Fee
State Tax
Slamp Fee
25 o/o of the Policy Promium is fully earned se of the effec-tivadate of this polhy and is nct subject lo raturn or refund.Service of $ult (if form CCp 20 10 is attrached) may bo made upon:
JH Insurancs $ervices
140 E.Suite 11 $a tD 8$fl64
COMPANY REPRE$$NTATIVE:
JH Insurance Services
120 €. La*e $t.
Suite 311
$andpoint tD S3BS4
il UnfHE$e WHEREOF, $id Compeny har exe{utgd aild sltsetad
Agent of thls Company st tho Agsni) hereinbefore mentioned.
Csntury_S_urety Company
465 Glevelend Avanue
Wcrtcrvllh, Ohto 41082
crr{[$.2dtil
ssy-c*ntu:yr*rrty_cstr
C0ltf llERClAL Lll'f E$ FOLICVcotilol{ PoHcY DHC LARAT|OI{ S
New
COnf NO.:SCI61A
INSURED$AGENT;
Kraft Lake Insurance AgenryP.O. Box 32788344r)
TOTAL
CountersigneS By
04$3t2t12
palicy rhall not b* valid urdess muatersigned by tie duly Authorizrd
{M-n*
$100.00
$150.00
$2S.46
$3.e1
$1,591.37
tfte$a pffosnl$l but lhis
ffi
Secretary
s) and Endorsement(s) mado a pertffi
$eo Attsched Schedule of Forms, CIL 15 00b 02 0l
c$GP 10 01 05 0s
President
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