HomeMy WebLinkAboutALL DOCS - 13-00334 - 875 S Canyon Rd - Aspen Fire Protectiona
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Rexburg, lD 83440
Rexburg -Modison Counly
Emrrgrncy Srrvlerr
Phonei 24ffi72,2341
Fox: 208.359.3022www.rexburg.org
REXBURG
At*:rittt\ tnnii1 Ct nmuflity
PERMIT#, I? bOffiLI
$rotF.;P"i
BY: Date:
"A tnfty ystem certfrcation perrnit it rvquired to install, nodfi, maintain, or seruice all new and existingfre
extinguishers,fre wppwssion gstens,fre alarrn gtstems, and otber lfe safeg gtstens within the Ci\' of fuxburg"
BUSTNE5sNAME: Mp"* Ftrzu_ FaLc'l-r^{Patcet-
oFFIcE ADDRES3 , tl = > , C-n-'Urt"rt: - V) )Vdate., , ,u l-'t* V4 LS:
oFFICE PHoNE NUMBEru BO r -TS 4 . OS b S
coNTAcT pERSoN: L*rt-i- q- L,rd-, CELL PH0NE *r *6 i*-\7 G-:5457
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECKALL
THAT APPLY.
FIRE ALARM SYSTEMS - Alarm Contractors shall have a minim\rr" of NICET Level 1
Cetifications ot equivalent.
T.PLEASE PROVIDE CERTIFICATIONS:
..!. NI CET Certifi cation
t Panel Certification
t Ptoof of Liability Insurance
I
ILeuroMATIc SPRINKI-ER SYSTEMS * Fire Spdnkler Conftactots shall have a
of NICET kvel III Certifications or equivalent.
€. PLEASE PROVIDE CERTIFICATIONS:
.:.NICET Cetification
.1. Any Additional Certifications
*Proof of Liability Inswance
FIRE EXTINGUISHERS
-STAI$DPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
SPECIAL HAZARD SYSTEMS
FTRE PUMPS
-AUTOMATIC FIRE EAINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
l-
***PLfuISE PROWPE NOCUMENTATION OF TRAINING LEWIS,
INSTALI},TION CERTIFICATIONS, LIABILITY INSURANCE, ETC. FOR ALL
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANYNAME:
COMPANYNA]VIE:
COMPA}IYNAME:
PHONE #:
PHONE #:
PHONE #:
**PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF
THIS FORM**
I certi$ that I have read this application and declare under penalty of pe{ury that the information contained
hetein is corect and complete. I agree to comply with dl city otdinances, adopted codes, and state l,aws
relating to the iustallatiou, modification, senrice, and maintenance of new and existing life safety eyetems. I
hercby authorize representatives of this city to inspect any wotk for purpoees. I am eithet the
and ,m acting with the owuet'sconftactot tesponsible fot the wotlc" ot I rcprcsent the owncl as signified
APPLICANT'S SIGNATURE
/conttactotts full knowledge or conseot.
t *.--e \rn n"-"-ri |, {
PRINT NAME OF APPLICANT
1 ^ lq^ zar\
DATE
PERMIT VALID UNTIL DECEMBER31 OF THE CAIENDARYEARAPPLIED FOR
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DISIPLINES***
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Page 2 ot 2
COVERAGES
zoa 3-09-23 I 3:04:46 MST 14664O4a312 From: Johanna Robin.ono
CERTIFICATE OF LIABILITY INSU
o
RANCE
CERTIFICATE NUMBER:2E/r3-REVISION }IUMBER:
#':"",5ilf1"#.Xsrs'suEcERrlFlcArE DoEs Nor AFFIRMAnvELy oR NEGAnvELy AMENo, ExrENo oR ALrER rHE covERAG-;1iE,ffiffi'ril!?ts?T;,ttBELow' THls CERTIFICATE oF lNsuRAttlcE DoEs Nor coilsrtruie A coNTRAcr BETWEEN rxe rsslrilc rNsuRER(s), AUTHSRTZEDREPRESENTATIVE OR PROOT'CER, AND THE CERTIFICATE HOLOER.
the terms and condlions of the policy, certain
cerlificdo holder in lieu of such endorsementl
-r, -guJsLa rupolicies may require an endorsement. A statement on this certiticde doss not confer righls to the
Leavitt Group of Spanish Fork,Inc
Insurance & Surety Bonds
P. O. Box 7ST, L99 North ttlain
Spanish Fork, UT 84660 Eurns & Wi'l coxrNsl,.REo Aspen Fire protectjo-n
E75 S Canyon Road
Santaquin, UT 846Ss
lll-r.lgr^I,f ,E",10^.-l,cJTNDPATED' NorwrrHsrA rDrryqANY ReournEuetti, rEiN on cor,ronior,r'oe-arw Col,iqb;{'cj|;E["""BflXt'*ii,,rtYfi [?!J$t "r"jfiL?ti+"rt"-E"TJli3"'jJSIfl:S^1TY,:RPIyaY:"tBn[rJ:'q H:*1*::g:^qliifi"-'le"porcres DEscRTBEDHERETN rs suBJEcr roALL rHE rERMsexclustorusmo coruororus orsucp por-rciei. r-riiir-s ilowN fiiffvE;rii,'*'."oiEEB i"'ioili?'r-"oil'J
COI\,IMERCIAL GENERAL TIABILITY
CLATMsMADE lTl oc.un
GEN'L AGGREGAIE LIMIT APPLIES PER
PoLrcyl lji'ct I lroc
AUTOMOEILE LNAILITY
ANY AUTO
ALLOWNED T__l SCHEDULEDAUToS I I AUToS
HTREDAUTos | | lSloort^to
BODILY INJURY (per pecon)
BODILY INJURY (per accidenr)
AID EMPLOYERS' LtiABtLtTyAp[EFS,"#F,I#;1;;;;',..,',utlfl(Mudatory in NH) r-l
lfyes. descibe underOF OPERATIONS below
E-1. DISEASE. EA
E.L, DISEASE. POLICY LIMIT
D€SCRIPNON OF OPERANONS' LOCAIIOHS r VCXrc
CERTIFICATE HOLDER
ACORD 25(201OtO5l
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CANCELLATION
the ACORD name and logo are registered marks of ACORDtrial version www. pdfactorv.com
FAX: 208.359.3003
City of Rexburg Idaho
26 North Center Street
Rexburg, ID 83440
SIIOULDAITY OF THEABOVE DESCRTBED POUCIES BE CAAEELLEO BEFORET}€ EXPIRANON OAIE THEREOF, NOTICE WILL AE OELTVERED INACCORDAIICE WtIH rHE POLICY PROVISIONS.
AUTTORIZEO REPRESENTATIVE i:-)**- rr(ilE;**>
fohanna Robinson,/JR
PORATION. AIl ]
I City of Rexburg Receipt#:416
Dare:8/?1n013
"!:ry,Uii'i.-:'Tmffi:: ,',,=: ;"'..::l. .
;*"**--- --"'-*""
Tolal Amonnt Due:
Total Pa;uert:
Code REIGtiRG_Recpt4 1 6_2 I _8_101 3_m andas
10s.00
100.s0
Fage I of IReceivedBv: a:umdro