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35N l.tE
Rexburg, lD 83440
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022
Rexbuig -Modison Cou nly
www.rexourg.org
oFFrcE pHoNE NUMBER, &O 8- SSa-afl,(
coNrAcr pERSoN, F S fV\a,tttvr^,,s -ft4LL pHoNE #:
bso A,Olaou - o{*PLEASE IDENTTFY SYSTEMS To BE covERED [y rnrs penrun- cHEcKALLTHAT APPLY.
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REXBURG
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America\ Family Ctttnflru nirv
*A toftU sltstem certifcation pernit is required to install, nodtfl, maintain, or seruice a// new and existingfreextinguishers,fire supprusion sltstems,lfire alarrz gtstems, and other lfe safe4t sltstem: within tbe C;4, oy{oOurg,,
BUSINESS NAME:arcel:
OFFICE ADDRESS:
-FIRE AI-ARM SYSTEMS - Alatm Contractots shall have a minimum of NICET Level 1Certifications or equivalent.
' PLEASE, PROVIDE CERTIFICATIONS:
*NICET Certification
{.Panel Certification
{.Proof of Uability fnsurance
{.NICET Level II required for design work
-AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have aminimum of NICET Level I Cetifications or equivalent.
{.PLEASE PROVIDE CERTIFICATIONS:
{.NICET Certification
{.Any Additional Certifi cations
{.Proof of Liabitty Insurance
{. NICET Level II required for design work
X "t*r
E*TTNGUT'HERS
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_/ i.Proof of Certification & Training
_A_AUTOMATIC FIRE EXTINGUISHING SYSTEil4S FOR COMMERCIALCOOKING
*Proof of training
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
For commetc-ial cooking heads
X snecrer rrezenD sysrEMS
-FIRE PUMP
*{.*PLEASE PROWDE DOCUMENTATION OF TRAINING IEWLS,
INSTAI^I.ATION CERTIFICATIONS, LIABILITT INSURINCE, ETC. FOR ALL
DISIPLINES**{'
I certi& that I have tead this application and declare undet penalty of perjury that the information containedhetein is cottect and complete. I agtee to comply with all city otdinances, adopted codes, and state lawsrelating to the installation, modification, service, and maintenance of new and existing liie safety systems. Iheteby authorize teptes€ntatives of this city to inspect any wotk fot compliance putpo-ses. I am eithet theconttactor tesponsible fot the work, ot I represent the owner as signified above and am acting with the ownerrs
/conftactot's full knowledge or consent.
Us* A-0 lso,t/
PRINT NAME OF APPLICANT
3-4-/3
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDARYEAR APPLIED FOR.:N.***:1.******************************************x*******x*********x*************
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CERTIFICATE OF LIABILITY
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INSURANCETHts cEnnFrclre r5r se uEo76T|'ll9vEn||r|9^rEls|ut'UEuAEAMATTEBoF'NFo.RMA1.|oltlg11gEl;fi'.";1..',..8pffili8lf5pH,tHih:glli"clly*{lti*i*tft]"jt:LrExtlE covERAcEAFFoRDED syrHE pouc,EsEiY;J$iifiiEH',i,L1,?tffiXf*,',tili+lfi"*ji',9,:^ffi,"'ildffiil8'r"T'l==Riinffi,?'=",gHf,lSH,t$'nrvn 'rur '; ,r uE Ge'.rrcire norder ra an ADDrtoNAt- lNsuREoSe poih-c!(ieErmriEiDceiEor€ea. ,f suiihr6AiibNls w;AivEb;di,b-iear" _ " __
;ffiffir:L""",l;l'flSl:S".nt#r#fin plolioit" mev require antnoorsement. A etElemenr on rhigcerriricate doee nor conrer rrshrs ro rhe
Montana hlernatlonal rns.
A Member of payne Financla! Group
P.O. Box 6127
Helena, MT 59604-0639
Ace Fire & Ufe Selety, LLC
1353 Elm Sr.
Helena, MT 59601
NeuiER B: Assoicaled lntemational
COVERAGEg CEFTIFICATE NUMBER:REVISION NUMEER;ts ro cERTtFy rxer txEtptg{rFD. r.rorwrnrsinNoii,,'o iiil"ii."oJ,'#';'dfi:}ffi,:'".ig1ti[jiit*:fg1g :Sl#g."3"4fti:l["Srv rs sueiici i6 eri iii; renr,rs,
.,-ATMg.MADE lrl *"u.
loL'clll_lj€di I lr-oc
cwP236010230
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P€RSONAL r AOV
AODILV trUURv (por ps|5q)
BODILY ttUURy (per soctdoht)
5
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AUTOMOALF LTABIL]rV
^LL owNED f--l scrisour_so
HIFED Auroc [| iictil-*owrueo
AND EMPLOYEFS' UAEIL]TY6IX EEgf;ru*?BEfeIUEE6.t eoulue #l(Mrn.totory In ilH)
DESCR|PTION OF Otu^^t o*tr roo^
Rexburg-Madlson Counry FlreDepartment
26 N. Center St.
Rerburg, lD Bg44O
SHOULD ANY OF T}IE AEOVE DESCFIEED FOUCIES EE CANCELLED EEFOBErHE ExprFAroN DArE ,x5l:pF, nonci'-rirli -#' *un=o=o rNACCOhDANCE r,lTH THE poltcv',enovtsroHs'.-- *
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