HomeMy WebLinkAboutALL DOCS - 13-00258 - 1224 11th Ave North Ext, Nampa - Shilo Automatic Sprinklers, Inc.a
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35N I'rE
Rexburg, ID 83440
Rexburg -Modison Cou nty
Emergency Services
Phone; 208.372.2326
Fax: 208.359.3022www.rexburg.org
cIlY olr
REXBURG
cS' -
Atnericai Family Cot ttnunit,
"A tnftA s-ltstem certfrcation petmit is required to install, modtfi, maintain, or seruice a// new and existingfire
extinguishers,fre suppression gtstems,fre alarrn slstens, and other kfe safetl gtstens aithin the Ciry of Rexbury"
BUSINESS NAME:
oFFIcE ADDRESS, t72{ L l,fuu h,n Al. Nla.rt^ln T.b tr3ur1
oFFrcE pHoNE NUMBER, Jat- 4lol* -oo" L
CONTACT PERSON, +A*N TC'*S CELL PHONE *Z h8_ 79O-OOOb
PLEASE IDENTIFY SYSTEMS TO BE COYERED BY THIS PERMIT- CHECKALL
THAT APPLY.
_FIRE ALARM SYSTEMS - Alarm Contactors shall have a minimum of NICET Level l
Certifications or equivalent.
' PLE,ASE PROVIDE CERTIFICATIONS:
{.NICET Certification
*Panel Certification
{.Proof of Liability Insurance
{.NICET Level II tequited for design work
__U_AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractots shall h2.ea
minimum of NICET Level I Cetifications or equivalent.
N.PLEASE PROVIDE CE,RTIFICATIONS:
{.NICET Certification
{'Any Additional Certifi cations
i.Proof of Liability Insurance
N. NICET Level II tequired fot design work
-FIRE EXTINGUISHERS
{.Ptoof of Cetification & Training
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
i.Proof of training fot commercial cooking heads
-/reNDpIpE sysrEMS .-- spEcIAL HAZARD sysrEMS
SMOKE CONTROL SYSTEMS ,,,- FIRE PUMP
{C**PLEASE PROVIDE DOCUMENTATION OF TRAINING IEVELS,INSTALLATION CERTIFICATIONS, LIABILITT INS(IRINCE, ETC. FoR ALLDISIPLINES***
I cetiS that I have tead this application and declate under penalty of periury that the information containedhetein is cottect and complete. i ng"". to comply with all "iiy orai'r,"o"es, adopted codes, and state lawstelating to the installation, modifi..tio.r, service, and maintenance of new and existing life safety systems. Iheteby authorize teptesentatives of this "ity to inspect any wotk for compliance putposes. I am eithet theconttactot tesponsible for-the wotk, ot I teptesenfth. o*... as signified anorr. una ,m acting with the ownetrs/con&actot's full knowledge ot corisent.
APPLICANT'S SIGNATURE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.**,l'*{.*****************:l'*tN*,R*******rr.*******************x************************
DATE
PRINT NAME OF APPLICANT
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CERTIFICATE OF LIABILITYINSURANCE
CO'I/ERAGES
THIS CERTIFICATE IS TSSUED NcERrlFlcArE DoEs NorAFFtRMArtvEr-v-oiiriCnrlvELY AMEND, eiiEr'rt oR ALrER *ie cbvLmGE AFF.RDED By rHE poLr'EsREiR$.lTf''i:Tfl"S'"135-',T"'#il::rl'rn"likSfi!?,iili.'o" "#NrRAcr eerweEN i,E rssurne rNsuRER(s), AUTH.RTZED-: lf the certificate hoiEElis an
ISU Cunnington & Associates
P.O. BOX 429
E"gl" rD 83616
Brenda E]-Lis
(2o9,) 672_6tgo (208) 375-8280
brendaG cunningt-rrii s . com
tilus Insu
Shilo Automatic Sprinklers fnc
L224 \!th Ave N
eNational Union Fire fns, Co.
c:Scottsdale fns Co
ns. Co. State of pennsvlvan
CERTIFICATE N UlvtBER:1 2 13 Mast'Hrs ts ro cERTtFy rHef rge por_rciE
ID]CATED. NOTWITHSTANDING ANY R|ERTIFICATE MAY BE ISSUED OR MAYXCLUSIONS AND COND ITIONS OF SUCI
S OF INSI
EQUIREM
PERTAI N
I POL|CTE,
JRANCE LISTED BELOW HNVC gI
ENT, TERM OR CONDITION OF A, THE INSURANCE AFFORDED B'i llMlTs sHn\ rNr ir^v u \/E D-rr
,EN ISSUED TO THE |NSU
NY CONTRACT OR OTHEfr THE POLICIES DESCRIB
REVISION NUMBER:-rEp NAMED neove FoRJHmIiFFEi'i6DI DOC,UMENT WITH RESPECT TO WHICH THISED HEREIN IS SUBJECT rO NII rHr TENUS,tD-NSF
ITR TYPE OF INSURANCE ]fuNSF
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LIMITS
3CP 200385701 )/ 30 / 2012
,/r/2oL2
)/30/20L3
€ACH OCCURRENCE g 1 ,000, 00C
PREMISES (Ea occurence)$ 100,00C
MED EXP (Any one peren)$ 5,00(
PERSONAL & ADV INJURY 1 , 000, 00c
N'L AGGREGA]E LIMIT APPLIES PER:GENERAL AGGREGA]E s 2,000,00(
PRODUCTS - COMP/OPAGG $ 2,000,00(
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UMEINED SINGLE LII/,IITra acc,dent)$ 1,000. Ooc
BODILY INJURy (per peren)
BODILY INJURy (per accidmt $
PrioPERTY DAMAGF{Per acqdent)$
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EXCESS LIAA
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$ 1. ooo. oor
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,/30/20L3
EACH OCCURRENCE $ 3,000,00(
oeo lx lnererurrotO 1o,oo(AGGREGA]E $ 3,000, 00C
D WORKERS COMPENSAIIONAND EMPLOYERS' UABILITY
0il8trfi E'fi JP#Ei$nrtiie"ecir've ff |(Mandarory in NHIIt yes, desoibe underDESCRIPTION OF OPFRATIONq h6h-'
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rc 3621182 (AOS)t/r/2oL3
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E.L. EACH ACCIDENT $ 1. OOO. OOf
E,L. DISEASE - EA EI'PLOYE $ 1.O00_oo.
A Professional Liabi1ity
retro ciate 9/3O/2OO9
E-1. DISEASE. POLICY LIMIT $ 1 ,000.0o0rcP 200386701 /30/2OL2 /to12s13 perdarm 1,000,00(
deductible 5,00C
DESCRIP'IION OF OPERATIONS I
Proof of Coverage Sdledule, if mtre space is rcqulred)
CERTIFICATE HOLDFR
Proof of Coverage
AIYUELLA IIUN
SHOULD ANY OF THE ABOVE.DESCRIBED POLICTES BE CANCELLED BEFORErHE EXptRAiloN DArE THEREoF, r.rorrcF' ilrii -6=
orUve*eo r"ACCORDANCE WITH THE POLICY PROVISTOTVS.
'-'-- _-
AUTHORIZED REPRESENTATIVE
Brenda EIIj-s/BRELLT -t-rl,r--^-tltx ZZA;-^>
o legs-2010 Acono conpoffiTha Aaif)pn n.m6 an.l laan a:a ranicfarad mrrlrc nf AnOpn
All rights reserved.
City ofRexburg Reccipt#:257
Date:6/28t2013
Tdel Anouatllue:
TddPrynent:
Code: RE)BURG_Rc q.257 ZB_6JOI3 aa&s
100,00
100.00
ReceivodBy: ^a&Prgcc I of I