HomeMy WebLinkAboutALL DOCS - 13-00086 - Nelson Fire Systems Annual Safety Certificationa)
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35N lstE
Rexburg, lD 83440
Rexburg -Mqdison Cou nly
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022www.rexburg.org
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REXBURG
Antericas Familv Ctntltltunitv
"A tofru slstem certfrcation pennit is required to install, modzfi, mainlain, or seruice all new and existingfre
extinguisbers,fre suppression gtstems,fre alann gtstems, and otber lfe safe4t slstens within tbe CiE ofRexburg,'
BUSINESS NAME: I{rl:or^ Fr. 51* L.,^, parcel:
OFFICEADDRESS: ltlt S. il41jar Scc Ur S{rrt
OFFICE PHONE NUMBER, XO '- "I {,tr. &3AO
CONTACT PERSON: B-- N"lz,rr..,CELL PHONE #: $ot -t-f 2-111A
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECK ALLTHAT APPLY.
-)'FIne ALARM SYSTEMS - Alatm Contactors shall have aminimum of NICET Level 1
C6tifications or equivalent.
{. PLE,ASE, PROVIDE, CERTIFICATIoNS:
*NICET Cerification
i.Panel Certification
{.Proof of Liability Insurance
TNICET Level II required for design work
AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Conftactors shall hzve a
minimum of NICET Level I Certifications or equivalent.
' PLEASE PROVIDE, CERTIFICATIONS:
TNICET Certification
..1. Any A dditional C erti{ications
{.Proof of Liabitity fnsurance
t NICET Level II requfued for design work
-FIRE EXTINGUISHERS
i.Proof of Certification & Training
-AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
{.Proof of taining fot commercial cooking heads
-STANDPIPE SYSTEMS -SPECIAL HAZARD SYSTEMS
-SMOKE CONTROL SYSTEMS -FIRE PUMP
*{CT'PLEASE PROVIDE DOCUMENTATION OF TRAINING LEUELS,
INSTAI^TATION CERTIFICATIONS, LIABILITY INSURANCE, ETC. FOR ALLDrsrPLrIuEs*{"t'
I certiS that I have tead this application and declate undet penalty of periury that the information containedhetein is cottect and complete. I agtee to comply with all city otdinances, adopted codes, and state lawstelating to the installation, modification, service, and maintenance of new and-existing liie safety systems. Iheteby authorize teptesentatives of this city to inspect any work fot compliance purpo-ses. I am eithet theconttactot tesponsible {or the wotk, or I teptesent the ownet as signified above and am acting with the ownet's
/conttactot's full knowledge or consent.
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1AI'I'LIUAN'I' APPLICANT'S SIGNATURE
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DATE I
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.*****rl.**:N.******x************:t {.***********{ ***********************x***rt *********
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TRAYELE.-.R5J Ona Towar Square, Hartford, Connecticut 061g3
TRAVELERS CORP- TEL: t-SOO-A?A*2199CONSTRUCTION . ELECTRTCALCOMMON POLICY DECLARATIOT.ISISSUE DATE: 11/Os/12
TNSURIN. COlipANy, tOLICy NUMBER: 4T-CO-B62KF4S2-TIL_12
TRAVELERS PROPERTY CASUALTY COI{PANY OF AMERICA
1 . NA'{ED INSI'RED AND MAILING ADDRESS:NETSON FIRE SYSTEMS(BEN NELSON DBA}148.I S. MAJOR STREETSALT LAKE CITY, UT S4115
2.
3.
POLIcy pgRIoD: From O6/Ot /12 to O6/Ot/1J 12:A1
LOCATIor.ts
Pr€rnl ses Bl dg .Loe. No. No. Occupancy Adctress
SEE :L TO 03
A.M. Standard T.lme atyour. maillng address.
4.qqYF.E$G€ PARTS TORMINC PART OF THIS POLICY AND IN5URING COMPANIES:coMMERcIAL GENERAL LTABTLITY cov PART oiCr-niiairirr,rs cG To o.t 11 os rrL
5. NIJMBENS OF FORMS AND ENDORSEMENTSFORMING A PART OF THIS POLiCYI SEE IL T8 01 10 93
6' SUPPL€|ENTAL POLTCIES: Each of the,fo'nor.r.r19 rs a sepanate policy
pot rcy ""ntulSli3rtffi.complete pnov't"?ffi;.,"n
.o*ou.,
DIRECT BILL7. PRE}'IUM SUMMARY:Provl slonal pr.em{un
Oue at InceptlonDue at Each
NAME ANO ADDRESS OF AGENT OR
GOBB STRECKER DUNPI1Y ZIM5 TRIAD CEMTER ST€ 34O
SALT LAKE CITY, UT 84I8O
IL TO 02 1l 89(REV. O9-O?)
oFFIcE I SP-SALT LAKE CITY
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TRAYFTER6?
POLICY NUMBER:
EFFECTIVE DATE:
ISSUE DATE:
4T*C0* 862K5452-TI L _1 2
06-0l -1 2
t I -o8-t 2
LISTING OF FORMS, ENDORSEI{ENTS AND SCHEDULE NUMBERS
THIS LISTING SHOT{S THE Aru!{BER OF FORMS, SCHEDULES AND ENDORSEMENTSBY LINE OF BUSII.IESS.
COMMON POLICY DECLARATIONS
FORMs. ENDORSEMENTS AND SCHEDULE NUMBERSCOMII|ON POLICY CONDITIONS
LOCATION SCHEDULE
GENSRAL LIABILITY . CONTRACTORS
cc To ol 11 03
cc To 07 09 87
cc To 08 tl 03
cc To 34 tl 03
cG 00 0l 10 0t
cc D4 20 07 08cc D4 71 02 0s
cG 20 31 07 04
cc 21 70 0t 08
cG t'2 03 t2 97cG D2 11 01 04cc D2 46 08 05
cc D3 16 l.t 1l
cG D2 43 0t 02cG D2 88 11 03cc D2 9A lt 03
cG D3 Q7 11 0e
cc D3 22 01 04cG Ds 26 .to 11cG D3 55 01 0scG D3 91 03 07cG D4 21 07 08cG D5 46 10 .tl
cc D6 t8 10 11
cG DO 76 06 93
cG D1 42 01 93
cc D1 73 11 03cG D2 04 06 01
cG D2 40 06 01
cc D2 42 01 02c6 T4 78 02 SO
CG T4 8J Jl ABcG ol 86 12 04
INTERLIM ENDORSEMENTS
IL T3 38 05 1O FEDERAL TERRORISf{ RISK INs ACT DISCLOSE
COI4L GENERAL LIABILITY COV PART DECDECLARATIONS PREilIIUM SCHEDULEKEY T0 DECLARATIONS pREr,tIUM SCHEDULETASLE OF CONTENTS
COI{M€RCIAL GENERAL LIAEILITY COV FORII{AMIND OTHER INS COhjD MEAN oTHER INS/INSRAMEND COVERAGE B - PERS & ADV IN.,'Ry---.-AOD'L INS.ENGINEERS, ARCI{ITECTS, SURVFYCAP ON LO5SES-CERTIFIED ACTS-TERRORISMAMEND-NON CUMULATION OF EACH OCCDESIGNATED PROJECT(S ) EEI.I ACEN-irUrrBLANKET ADDTTToNAL INSURED {COmrucrons )CONTRACTORS XTEND ENDORSEMENT
rUNGI OR EACTERIA EXCLUSION
5!.!|!0IMENr*RELATED pRAcrrcES EXCLUSTONEXCL.CONSTRUCT MANAGE €RRORS A OMTSSTOilJSE XCL US I 0N-CONTRACTOR S - PROFE SS r Or,tnr_ r_ r AeEXCLUSION.SUITS BY ONE NAMED TruSUNEOEXCLUSION - UNSOLICITED COMMUrVriArrAr,r
S|!I!F EQUIP/rxcL vEHrcLEs suB-io- Mv LA14EXCLUSIoN-PR0rJECT SUBdCCT ro wnlp up
lf4FND CONTRAC LIAB EXCL_SXC TO Hnuep rruslM - ARcHrrEcr./eruelsuevev pnoF"sEev
EXCL-WOLATION OF CONSUMER FIN PNbr UAYSEXCLUSION_LEAD
EXCLUSI ON-DI S CR IMINATI ONAMEND-POLL EXCL-INCL LTD COV POLL COSTSEXCI-EXTERIOR INSULATION & FiNI'i SYSTEMEXCLUSION - SILICA
SXCLUSION WAR
EXCLUSION.ASBESTOS
EXC-HAZARD.CONNECTED DESTGNATED EXPOSUREUTAH CHANGES
IL TO 02 11 89IL T8 01 ro 93
IL TO Ol 01 07
rL TO 03 04 96
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TRAYELERs?
poLtcyNUMBER: 4T-CO-852K5452_TIL-12
EFFECTTVE DATE: 06_01 _12
ISSUEDATE: it-oe-12
INTERLINE ENDORSCMENTS (CONTINUED )
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rL o0 21 09 08IL 02 66 09 08
MJCLEAR SNERGY LIAB EXCLUT CHANGES-CANCE LLATI ON
END.BROAD FORM
& NONRENEWAL
rL T8 01 10 93 PAGE:20F
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revelopment Receipt Number: 13{1iX
). 83440
r08) 359-3022
to
Payer/Payee lrlgme:
$ 100.00
MAR 1 2 ZO13
clw oFREXBURG
genpmtrreceipts Page 1 of 1