HomeMy WebLinkAboutALL DOCS - 13-00257 - 2510 S W Temple, Salt Lake City, UT - Western Automatic Sprinkler Annual Certificationa)
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35N l,rE
Rexburg, lD 83440
Rexburg -Mqdison Counly
Emergency Services
Phone; 208.372.2326
Fox: 208.359.3022www.rexburg.org
"A tnftu s-ltsten ceftzfmtion permit is required to install, modtrt, maintain, or sentice all new and existingfreextinguishers,fre suppression s-ystems,fre alarrn slstems, and other lfe safelt ;ystens withf n the Cl4, of Rexburg,'
BUSTNESS NAME: ll.)(:*(.i n hr'",lroniritrc (-r lns"ei",
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OFFICE PHONE NUMBERT
.ELL PH.NE #, x)i"15[-zlil
c|lY otr
REXBURG
Americal Familv C<lntilunitv
CONTACT PERSON:
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECKALLTHAT APPLY.
-FIRE AI-ARM SYSTEMS - Alarm Conftactors shall hzve aminimum of NICET Level 1Certifications or equivalent.
* PLE,ASE PROVIDE, CE,RTIFICATIONS:
a?.NICET Certification
{.Panel Certification
I *NICET Level II required for design work
V-EUTOMATIC SPRINKLER SYSTEMS * FirC SPdNKICI CONtTACtOTS ShAII uAVC Aminimum of NICET Level I Certifications or equivalent.
t!. PLE,ASE PROVIDE, CE,RTIFICATIONS:
.}NICET Certification
{.Any Additional Certifications
{.Proof of Liability Insurance
* NICET Level II requfued for design work
-FIRE EXTINGUISHERS
:?.Proof of Cetification & Training
AUTOMATIC FIRE EXTINGUISHING SYSTEil4S FOR COMMERCIALCOOKING
{.Proof of taining for commercial cooking heads
-STANDPIPE SYSTEMS -SPESIAL HA2ARD SYSTEM5-SMOKE CONTROL SYSTEMS FIRE PUMP
***PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,INSTALLATION CERTIFICATIONS, LIABILITY INST]RANCE, ETC. FoR ALLDISIPLINEST**
;::::T::::,:*ff*:j]1. y:5 or r reptesent the owner as signified aro.,. .,,a "- aJngwith/conttnctot's full knowledge ot consent.
I certi$ that I have tead this application and declare under penalty of periury that the information containedhetein is cottect and complete. I agtee to comply with all city ouin"n"es, adopted codes, and state lawstelating to the installation, modification, setvice, and maintenance of new.nie*i.ting rii. "rr.ty systems. Iheteby authorize teptesentatives of this city to inspect any work fot compliance purposes. I am either the
PRrNT NA\4E OF 4ylnuceNr
DATE
APPLICANT'S GNATURE
PERMIT YALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.**********************************************rt ***rt *:t **************************
2-
Client#: tl OWESTAUACORD,"CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED Ag A ijlA
CERTIF]CATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONST|TUTE A CoNTRACT BETWEEN THE |SSU|NG INSURER(S), AUTHORTZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
||IrvK.ANl:1IInecen|r|caIeno|oer|sanADD|T|oNAL|NsUREo'thepo|icy(ies)mustbeendors
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement{s).
PRODUCER
Leavitt Group Ins Advisors
465 South 400 East #300
Salt Lake City, UT 84111
801 308-1500
Western Automatic Sprinkler Corporation
2510 S West Temple
Salt Lake Gity, UT 84115
tNsuRER B: Workers Gompensation Fund
6, First National Insurance Co of
REVISION NUMBER:THIS IS TO CERTIFY THAT TI.IE POLICIES OF INSUM
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUMNCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA|D CLAIMS.
TYPE OF INSURANCE twD POUCY NUMBER PIM EXP LIMITSAGENERAL LIABILITY
Xl couuencnl oENEnaL LtABtLtry-T-l
.LAIM.-MADE l-il o""r*
Xl BI/PD Ded:5.000
GLO939810103 11t01t201301101t2011EACH OCCURRENCE $ 1.000.000
tE TO RENTEDiES aFa 6c.r'rrandl $ 100.000
MED EXP (Any one pe6on)$5.000
PERSONAL & AOV INJURY $ 1.000.000
J GENEML AGGREGATE s2,000,000GEN'L AGGREGATE LIMIT APPLIES PER:
I por-rcv I Xl ',Fc"i I I r_oc
PRODUCTS. COI\,IPIOP AGG s2,000.000
c AU'
T
T
TOMOBILE LIABILITY
ANY AUTO
ALL OWNEO
AUTOS
HIREO AUTOS
f-l scneouleoL_J AUrOS
I v I NON-OWNED
l_n_l Auros
tl
25CC1348387 t1t01t2013011011201t(jOMBINED SINGLE LIMI'I s1,000.000
BODILY INJURY (Per peBon)$
BODILY INJURY (Per accid€nt)
PROPERW DAMAGE
A UMBRELLA LIAB
EXCESS LIAB
OCCUR AEC5509046300 ,1t01t201301101t201EACH OCCURRENCE $2,000,000xX lcutt',ts-ttreoe AGGREGATE $2.000.000oeo I Xl nererrrorus10000 oBAND EMPLOYERS' LIABILIW
alif pgfift filgJeniiirirxec urrv e lfr(Mandatory In NH)
lf y€s, describe und€rDESCRIPTION OF OPERATIONS betow
N'A
1606104 t1t01t201211t01t201iv lwcsTAru- | loTH.n lTORYllMrTq I ltrp
E.L. EACH ACCIDENT $1.000.000
E.L. OISEASE . EA EMPLOYEEs1.000.000
E.L. DISEASE . POLICY LTMIT s1.000.000AContractors
Design Liability
GLO939810103 1t01t201301t01t201t1,000,000 each act
2,000,000 aggregate
5.000 deductibleDEscRlPTloN oF oPERATloNs, LocATloNs / vEHICLEs (Attach ACORD 101, Additlonat Remarks schedule, lf more apace is required)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCOROANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Qa* 6-...t"*aa
O 1988-2010 ACORO CORPORATTON. A[ rights reseryed.ACORD 25 (2010/05)
10249#s34941/M32985I of 1 The ACORD name and logo are registered marks of ACORD
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Name:
Date of Award:
Certification Number:
Certification Expire Date:
NATIONAL INSTITUTE FOR CERTIFICATION
Providing Certif ication programs 5ince l96t
ffiffim
Approval Letter
remove card slowly
NATIONAL INSTITUTE FOR CERTIFICATION
IN ENGINEERING TECHNOLOGIESO
R.ohent ts. f,Iagen
Robert B. Hagen
NIay 2,2011
70982
05t01/2014
It is my pleasure to inform you that recertification has been granted as follows:
FIRE PROTECTION ENGINEERING TECHNOLOGY/WATER-BASED (FORMERLY AUTOMATIC SPRINKLER)SYSTEMS LAYOUT/LEVEL IV
You will find your new wallet card attached to the bottom of this letter. Also enclosed with this letter is your new certificate.Your new three-year period of certification is printed on both your wallet card and your certificate. you will need toaccumulate another 90 continuing professional development points to continue youicertification beyond this new expirationdate.
Prior to removing the wallet card from this letter, we advise that you make a copy of the letter for your files as the compldeletter may be required as proof of certification.
The interest you have shown in your career development by obtaining professional recognition and status through certificationis most commendable' on behalf of the Board of Covernors, please accept our congratulations and best wishes.
Very truly yours,
rMu
Michael A. Clark
Chief Operating Executive
Robert B. Hagen
Western Auto-matic Sprinkler
2510 S West Temple ^
salt Lake ciry, uT 94115-3035
w.arER-tsAsED(89$+$t[*I^t"J"w$rcspRrNKLER)
CERT NO. 70982 VALID THRU O5/OI/20I4
1420 King Street, Alexandria, VA 22314-2794 888-476-4238 +1-703-548-1 518 703-682-2756 tax
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t City ofRexburg
Sub Tdrl:
Receipt#: 255
Date:6/28D013
To{al Amountl)ne:
Total Peyment:
Co&: RE)GURG _REqt255 28_6]013 aa&s
100.00
100.00
RcceivedBy: ruadas Prgc I of I