HomeMy WebLinkAboutALL DOCS - 13-00101 - SL Fire Protection Annual Fire Safety Certification35 N ldE
Rexburg, lD BU40 www.rexburg.org
Rexburg -Modison CountY
Emergency Services
Phone: 208.372.2341
Fox:208.359.3022
PERMIT#:
$100 Fee Paid: Yes/No Permit Apptoved: Yes/No
By: Date:-
*A safery ysten nrtifcation pernit is requircd to install, nodtfi, or sentice all nea and existingfre
extinguishers,fre sappression'gstens,fi alarn gtstems, and itber t{e safeg gstens within the CiE ofRtxbury"
BUSINESS NAME:
OFFICE ADDRESS:
oFFrcE pHoNE NUMBEn, t135-773'1b71
coNTAcT PERSoN:JOSI'n SoeN cELL PHoNE #:Lt35 1fr-As81
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL
THAT APPLY.
FIRE AI-ARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level1
Certifications or equivalent.
{.PLEASE PROVIDE CERTIFICATIONS:
*NICET Certification
*Panel Cetification
'i'Proof of Liability Insurance
_X_AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shallhave a
minimumofNICETLevellllCetificationsorequivalent.
{.PLEASE PROVIDE CERTIFICATIONS:
{'NICET Certi-fication
{'Any Additional C erdfications
{'Proof of LiabilitY Insurance
FIRE EXTINGUISHERS
STANIDPIPE SYSTEMS
-SPECIAL
HAZARD SYSTEMS
-STVTOKE
CONTROL SYSTEMS FIRE PUMPS
_,luroMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
cI'tY 0ir
REXBURG(\r ..-
A*erica\ Fa miiY Comm u rii tY
-l
*#PLEASE PROWDE DOCAMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITY INSURANCE ETC. FOR ALL
DTSTPLTNES*tc{'
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANYNAME:
COMPANYNAME:
COMPAI.IY NAME:
PHONE #:
PHONE #:
PHONE #:
**PLEASE LIST ADDITIONAL COMPAT{Y AUTHORIZATIONS ON THE BACK OF
THIS FORM#
I cettiS that I have tead this application and declare undet penalty of petiury that the iaformation contained
herein is correct and complete. I agtee to comply with all city ordifrances, adopted codes, and state laws
telating to the installation, modilication, setvice, and maintenance of new and existing life safety systems. I
hereby authorize rcptesentatives of this city to inspect any wotk for compliance pu{poses. I am eithet the
contfactof tesponsible fot the wodq ot I reptesent the ownet as signified above and am acting with the owncds
/contractods full knowledge or consent.
.T-.^n €n -.n,
PRINT NAME OF APPLICANT
03- 2o -.1?
APPLICANT'S SIGNATURE
DATE
PERMIT VALID UNTIL DECEMBER 31OF THE CALENDARYEAR APPLIED FOR.
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CERTIFICATE OF LIABILITY
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Totrl Pryment:
Co&: REXBURG-Recptz58 28-6-201 3-aadas
Receip#:258
Date:6/28D013
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ReccivedBy: aadas P4er I of I