HomeMy WebLinkAboutALL DOCS - 13-00011 - Viking Automatic Sprinkler Annual Certificationa
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35N l.tE
Rexburg, lD 83440
Rexburg -Modison Counly
Emergency Services
Phone: 208.372.2341
Fox: 208.359.3022www.rexburg.org
CITY OF
REXBURG
(\t -
4 mc ric*'s Fr mily Cmnumi iy
$100 Fee Paid: El Yes n No Permit Apptoved: f] Yes n No
PERrS{T#:
rid: EI Yes I
BY:Date:
*A toftA ysturn certifcation perrzit is required to install, modifi, maintain, or seraice a// new and existingfire
extinguishers,fre suppression lystens,fre alarrz gstems, and other life safery ysterzs within the Ciry of Rexburg"
BUSTNESS NAME: Viking Automatic Sprinkler Co. pa
OFFTCE ADDRESS. 32 E. Bower St. - Meridian, lD 83642
oFFTcEpHoNENUMBER. Qo8)888-2762 nnz liSS& . ratlt-rtHncl Wntler.-.--:-. /,ef
coNTAcT pERSoN: Ron A. Larson, VP 6ELL pHoNE +' (20t1999 %91
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECK ALL
THAT APPLY.
E fInB ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level 1
Certifications or equivalent.
.T.PTN,ESP, PROVIDE CERTIFICATIONS:
*NICET Certification
*Panel Certification
.!.Ptoof of Liabilitv Insurance
E eUfOnaeflc SPRINKLER SYSTEMS - Fire Sprinkler Contractors shall have a
minimum of NICET Level III Certifications or equivalent.
.I. PLEASE PROVIDE, CERTIFICATIONS :
TNICET Certification
{.Any Additional Cetifications
*Proof of Liabilitv Insutance
n rrnB EXTTNGUISHERS
.f.Proof of Certification & Training
n eurouetrc FrRE ExTINGUISHING SYSTEMS FoR coMMERcIAL
COOKING
.i.Proof of training for commercial cooking heads
V!
STANDPIPE SYSTEMS
SMOKE CONTROL SYSTEMS
E spBcnl HAZARD SYSTEMS
EI rtnn PUMPS
It-
* * *PLE/4SE PROWDE DOC UMENTATI ON OF TRAININ G LEWLS,
INSTALLATION CERTIFICATIONS, LIAB ILITY INSURAN CE, ETC. FOR'4LL
DISIPLINES***
BUSTNESS NAME: Viking Automatic Sprinkler Co
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANYNAME:
COMPANYNAME:
COMPANYNAME:
COMPANYNAME:
COMPAT{Y NAME:
COMPANY NAME:
COMPAT{YNAME:
COMPANYNAME:
COMPAT{Y NAME:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
I certi$ that I have read this application and declare under penalty of periury 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 the
contractor responsible for the work, or I represent the owner as signified the ownet's
/contractot's firll knowledge or consent.
Ron A. Larson. VP
PRINT NAME OF APPLICANT ATURE
December 21.2012
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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DATE (MM/DDIYYYY}
oI/ 3t/ 2oL2
59 glll?t l1YliY* ^'"*j::: l:lMl'uKlANl; lT fne gsrullualE llulusr rD
thetermsandconditionsofthepolicy,certainpoliciesmayrequireanendorsernent. Astatementonthiscertificatedoesnotconferrightstothe
certificate holder in lieu of such
pnooucen gotEga 1-503-274-6511'
Fullerlon & ComPanY laaurilce
PO Box 29018
503-274-5524503 -27 4-65!r
kdi ckinaon@f ullertonco . con
INSURERAT NAIITIIJIIS INS CO L731 0INSURED
viking Automalic 9Priak1er Co.,
3245 Nw Front Avenue
Portland, oR 97210
INSURER B: TRAVELERS MD Cq 255s8
lNsuRERcr CEARTER OA.K AIRE INS CO
I
,- &ACORD
THlscERT|F|caretstssffitoNoNLYANDcoNFERSNoR|GHTSUPoNTHEcERTlFlcATEHoLDER.THlS
:ERlFlcA,rE DoEs Nor AFF|RMATTVELY oR NEGATVELY AMEND, EXTEND oR ALrER rHE covERtG^F,.llFP:?.t3j:,tTi"t-?tJ:j;t:'EKllrlWAlE svee rlvr F
,ELOW, THIS CERTTFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S)' AUTHORIZED
REPRESENTATTVE OR PRODUCER, AND THE CERTIFICATE HOLDER'
CERT|FICATE NUMBER: 2s3 e73s1 REVISION NUMBER:
CERTIFTTT OF LIABILETY INSUNTCE
INSURED NAMED ABOVE FOR THE POLICY PERIODTHIS IS TO CERTIFY THAT TI
tNDtcArED. NorwrrHSrANDlNG ANY REoulREMENr, rERM oR coNDlrloN oF ANY coNrRAcI:I-?l1E5Po-"-',J=,I1"*lll s"ti::t"TP *ll+Jll':ll\ul9AlEu. r\vr vvr I t rer^rru
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN HT IruSUREruCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS'
EXCLUSIONS AND CoNDtTIoNS OF SUCH pOLtctES. LIMTTS sHowN MAY HAVE BEEN REDUCED BY PAI_D 9!t!!{s.
EACHoccuRRENce I $ 1r!!91!!98CP200453300
COMt\,4ERC|AL GEN ERAL LIABILITY
.rA.MS-MADE lTl o."r*
AGGREGATE LIMIT APPLIES PER:
g 100,000
2,000,000
5 2, 000, 00O
$ 1,000,000COMBTNED SINGLE LIMIT
(Ea accident)D?8 10L42LN44 5
ANYAUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
BODILY INJURY (Per PeFon)
BODILY INJURY (Per accident)
S 4, 000, 0000L/3L/L3FFX2 00453400
s 4,000,000
WORKERS COMPENSATION
AND EMPLOYERS'UABIUTY Y/ N
ANY PROPRTETOR,/PARTNERYEXECUTIVE [---1OFFICERYMEMBER EXCLUDED?
(Mandatory in NH)
Verificaiioa of Insurace.
SHOULD ANY OF THE ABOVE DESCRTBED POLTCIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
COVERAGES
HOLDER
CITY OF REXBT'RG BI'II,DING DEPT.
- - NORTII 1ST EAST
REXBIIRG, TD 83440
CANCELLA
O 1988-2009 ACORD CORPORATION' All rights reserved.Katied
A"r9l9riu (2ooe/os)The ACORD name and logo are registered marks of ACORD
Client#: rl;,AUTO2
ACORD,"CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYN
1t10t2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF ]NFOR
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE rSSUlNc tNsuRER(S), AUTHORTZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
|MPoRTANT:|fthecertificateholderisanADDlT|oNAL
the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to thecettificate holder in lieu of such endorecmantrcl
PRODUCER
Propel Insurance
Portland Commercial Insurance
888 SW Sth Avenue, Suite 1170
Portland, OR 97204-2025
CUN TACINAME:
ln8 no,e,o,503 467-7540 | lil ".. 866 57t_i,r6
E.MAIL
ADDRESST
INSURER(S} AFFOROING COVERAGE NAIC #
lrysuRER A , Nautilus Insurance Company
Viking Automatic Sprinkler Gompany
3245 NW Front Ave
Portland, OR 97210
tNsuRER B, Travelers Indemnity Company
INSURER C :
INSURER D :
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
THIS lS To CERTIFY rHAr THE PoLlclEs oF lNsuMNcE LISTED BELOW HAtEBEENtsSUED ToTHE r,tsiJREo NAMEDABovE FoRTHE polidFEiroo-INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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, LIMITS SHOWN MAY HAVE BEEN REDUCEO BY PAID CLAIMS.
WPE OF INSURANCE POLICY NUMBER EFFrYYYI
'EXP
LIMITS
A GENERAL LIABILITY
Xl courrlencnr- cENEnel LrABrLtry*--r--]
I lclrrr',rs-ruroe I Xloccun
.Xl BI/PD Ded:5,000
ECP200453301 t0t31t201201t31t201,EACH OCCURRENCE $1.000.000
BASSE"{?g'J:J$g*"$100.000
MED EXP (Anv one oerson)$5.000
PERSONAL & ADV INJURY s'1.000.000
.){ WA Stop Gap GENERAL AGGREGATE s2.000.000
GEN'L AGGREGATE LIMIT APPLIES PER:-l ro.,"" f-ilfS"q I-l ro"PRODUCTS - COMP/OP AGG s2,000,000
!
B AU'
T
T
IOMOBILE LIABILITY
ANY AUTO
ALL OWNEDAUTOS
HIRED AUTOS
T-l SCHEDULED
L-J AUTOSI v I NON-OWNED
l_4--l Auros
tl
DT8101421 N445 ,1t31t201201t31t201iCOMAINED SINGLE LIMITlEa amid€ntl s1.000.000
BODILY INJURY (Psr p€6on)
EODILY INJURY (P6r accidsnt)
PRUHhf{ I Y UAMAGE(Per accidenl)
A I UMBRELLA LIAB
xl ExcEss L|AB
X I occun_l
".o,^r"-^ron.
FFX200453401 101311201201t31t20uEACH OCCURRENCE $4.000.000
AGGREGATE $4.000.000
l,,o-e_o_l*lnere[rlory*g___
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORYPOR''.I ERYEXE"'''U= J4OFFICEFYMEMBER EXCLUDED? I I
(Mandatory in NH)
lf yes, describ€ underDESCRIPTION OF OPERATIONS below
N/A
-lf1ds1a1rr- T--lori.
E.L, EACH ACCIDENT
E.L. DISEASE. EA EMPLOYEI
E.L. DISEASE. POLICY LIMITA
A
Pollution
Professional Liab
ECP200453301
ECP200453301
t0t31t2012
t0131t2012
011311201t
0113112011
$1,000,000, $5,000 Ded.
$1,000,000, $5,000 Ded.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additionat Remark Scheduto, if moro space b requirod)RE: Operations of the Named lnsured.
City of Rexburg Building Dept.
35 North 1st East
Rexburg, lD 83440
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIMTION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 25 (2010/05)
fs1068215/M10311 of 1275
@ 1988.2010 ACORD CORPORATION. Ail rights reserved.
The ACORD name and logo are registered marks of ACORD
cxc00
@ nuo1uo1,
;:T"ffiHr.".,";"everopmenr Receipt Number:13qI8 -- :i:1.,:,
35 North 1st East / Rexburg, lD. 93440
Phone (208) 359-3020 | Fax(208\3Sg-3022
13 00011 Base Fire Fee
CHECK 53984 $ 100.00
Total:$100.00
genpmtneceipts Page 1 of 1
Client#: 131358
CERTIFICATE OF LIABILITY
VIKIAUTO2
INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INTON
::l:ll"i'i5:9s,:iEtrl'5iTlM:f:91l5^GLlyE^lY.l!.lID_,_ExrEND oR ALTER rHE covERAGE AFFoRDED By rHE poLrcrEsBELow. rHls cERrlFlcArE oF tNsuRANcE DoEs Nor corusrrrurl A coNrRAcr BETwEEN trr l*"u=,ni?i,'""rtffi"-fr;, iTrffiffiLTREPRESENTATIVE OR PRODUCER, AND THE CERTIFTCATE HOLDER.
IMPORTANT: lf the certificate holder '"
"n OO
the terms and conditions of the policy, certain policies may requiie an enddrsement. A statement on thiscertificate holder in lieu of such endorsement(s certificate does not confer rights to the
PRODUCER
Propel Insurance
Portland Commercial Insurance
888 SW Sth Avenue, Suite 1i70
Portland, OR 97204-2025
Viking Automatic Sprinkler Co
3245 NW Front Ave
Portland, OR 97210
tNsuRER B . Continental Insurance Company
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES O
Bl??+T"?."ffy1!.RT,?H""ly^J:?g'ffyr\r;"r=,S$,g^T.,g9l"_,1"J:9t ll"_qgyl g]_gn oriri"n"'oocuMENr wrH REspEcr ro \^,lrcH rHrsCERIFTGATE MAY BE rssuED oR MAY PERTATN, rHE rNsuRANce niioCoib'Bv_H;';offiLi'bis'ih''Ee6"iEiillii"J"!.lr.ll..Y?b';.i filc|eJil8EXCLUSIoNS AND coND . PoLlctES. LtMtrs sHorrvrv raqi iinve eeeH REDUcED By pArD crArMS.
COMMERCIAL GENERAL LIABILITY
.LATMS-MADE l- xl o."r*
GEN'L AGGREGATE LIMTT APPLIES PER:
PoLlCYl Al jii:-r I ILOc
ECP200453301
AUTOMOBILE LI,ABtUTY
ALLOWNED I ISCHEDULEDAUTOS LJ AUTOSI v I NON-OIMIIEDHTREDAUTOS l,\ lAuibs
BODILY INJURY (per peson)
BODILY INJURY (Per accident)
OCCUR
CLAIMS-MADE
WORKERS COMPENSANON
AND EMPLOYERg UABILITY
$1,000,000 $5,000 Ded.
$1,000,000 $5,000 Ded.
DEscR|PnoNoFoPERAnoNs/LocAnoNs/vEH|cLEs(AttachAcoRD1ol,Additiona|i@
RE: Operations of the Named Insured.
City of Rexburg Buitding Dept.
35 North 1st East
Rexburg, lD 83440
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
@ r988-2010 ACORD CORPORATION. AtlThe ACORD name and logo are registered marks of AGORD
cxc00
ACORD 2s (2010t05)1 of 1#sl 077008/M 1077001
rights reserved.
Certificate of Insu rance
Effective immediately, Propel Insurance will no longer issue certificates of insurance
not handled in accordance with statutory laws. We will only issue the most current
edition of the ACORD@ certificates of insurance. ln addition, the only information
allowed to be entered in the Description of Operafions area of the ACORD@ certificates
of insurance are the description of operations, the locations and/or vehicles covered by
the in-force policy.
The issuance or modification of a certificate of insurance that in any way misrepresents
any materialterm, condition, coverage or other provision as set forth in the policy, or
deliberately or falsely amends or alters the insurance policy or assists in such issuance
or modification violates the state law and subjects the violator to civil and criminal
penalties.
Please note a certificate of insurance is simply a summary of the designated insurance
policy and does not / cannot modiff or amend the referenced insurance policy or confer
any right upon the certificate holder. ln addition, the certificate holder is owed no duty to
be notified in the event the insurance policy is cancelled.
For purposes of this notice, "certificate" or "certificate of insurance" means any
ACORD@ certificate of insurance, which is prepared or issued by an insurer or
insurance agent as evidence of property or casualty insurance coverage but does not
include an actual copy of the insurance policy or insurance binder.
Please contact your state department of insurance for further explanation or inquiries.