HomeMy WebLinkAboutALL DOCS - 13-00170 - 925 Widdison Ln - Deck Additioni:,:*fitii:r:r:
Building Sofety DePorlmenl
City of Rexburg
www.rexourg.org
Phone: 208.372.2326
Fox: 208.359.3022
CITY OF
REXBURG'-.- ..... c\,
America\ FamilY ConmunitY
Office Hours: Monday-Friday 8:00am-4:00pm
Pre-Cons
Seismic Design CategorY - D
Gtound Snow - 50 lbs. Pet sq. ft.
Frost Depth - 36'
Roof Snow Load - 35 lbs. Pet sq. ft.
Wind Load - 90 MPH
Thefottowing iterus should be conpteted !4fure1ou nbmitlour buildingpemit @plication'
Completion ofa Buildiag PemitApplicatioa: Yotmay print this application from our website
or pick rrp " .opy at the city Hall Annex Building (address above).
Fot Residcntial permits.. (the f,ollowing is required to be submitted before the Application can be approved)
tr 2 sets of site plans and 2 sets of building plans (must be drawn to scale)
-plans must include foundation plan, flo=oi loist l"yout, floot plan, roof layout, sectional views, front, back'
and side elevations, mechanical Lyout, stair detaili and any details requfued to illustrate special construction.
tr Energy Compliancl Reporfi The State of Idaho has adopted the International Energy Conservatiorr Code
GECC) A Ctmplian.. R.rrie- must be completed and submitted (the rescheck software is available online
at www.energycodes.gov)'
tr page 2 of th.@; must includs the Idaho Contractor's Registration Number or the exemption fotm
must be completed and signed, see Page 10.
tr Page 5 of the Application must be completed and si,gned by your Plurnber.
6 prg" O of the Application must be completed and si.gned by your Mechanical Contractor.
tr fa!. a of the Application must be completed and sigped by yo,tr:Ele:ctriiln.
tr Home owners' pi."r. complete page 6 of the application if you will be doing your own electrical work'
tr Truss details including engineered floor ioists are requited'
r] Property Line form needs to be signed by the builder of ou/nef' see Page 4'
Subdiuisions: If you plan to build in a subdivision please check the Rexburg Development Code l:: ?"\
requirements such as, property setbacks, architecture board approval, etc. This information is available from the
Planning &ZonngDepaitment at the Annex Building located at 19 East Main'
New Residential lfomes: If your building permit is for a new home, you will need_ the parcel number (a paral
number is the coun!,s propey iden:tfrcation whii ingniry a ptot of knd) and a new physical addtess will be issued. If you
do not know the p"r..t rrrrmbei and cannot fini, t..otd of it, please bring the name of the subdivision, phase, and
the lot and block numbers. The correct location is vital to assure corect addressing.
Remodels:If you are considering a temodel, a g4y of the bid or estimate fot the remodel must be submitted with
the Permit Application..2 sets of Plans are required (may need IECC Review)'
. Additions are the same requitements as new construction'
CTTY O
c\' "--" .--
America\ Fomily CommunitY
RESIDENTIAL BUILDING PERMIT APPLICATION
35 N 1" E,, REXBURG,ID 83440
208-372-2326
PARCEL NUMBE,R:
-(
\7e will prcvide this for you)
SUBDIVISION:UNIT# BLOCK# LOT#
(Addressing is based on the infotmation - must be accurate)
Dwelling Units:Parcel Acres:
REXBURG
Please Complete the Entire Application!
If the question does not apply fill in NA for non applicable
o
F
:: t4,a'tii itt t; t ,' CONTACT PHONE # 5's"b "{.' el '/
pRopERT\.ADDRESS:'itt' lt;'il,sc,'r. Liu< ii"i//'utJ
PHONE#:Home (i;r") ':;s6 {tt? Work( )
owNER MAILING ADDRESS ' /oLs- ii' ;rl'l'i s t't. /vt' CITY:
APPLICANT (If other than owner)
@-ppli-."rr, ir *nei than owner, a statement authorizing applicant to act as agent for owner must accompany this application')
APPLICANT INFORMATION: ADDRESS CITY:
STATE; JIP- EMAIT. FAX
pHONE #: Home ( )- Wotk ( )-- Cell ( )
CONTRACTOR: -5
MAILING ADDRESS:it] C CITY Arw?)-nP 'F'sy'w
pHoNE #: Home ( )- \rork ( )- cenp4 fi:f -l-t| 7" -r),, r. _ tTrl IFMATT. FAX-- IDAHO REGISTRATION # & EXP. DATE F L k-- /
How many buildings are located on this prope
Did you recently purchase this property? ,No Yes (If yes, list previous owner's name)
Is this a lot split? Nb YES @lease bring copy of new legal description of property)
PRoPosEDUSE' l)i{
(i.e., Single Family Residence, Multi Family, Apartments, Remodel, Gange, Commercial, Addition' Etc')
started within 180days. Permit void if work stops for 180 days'
I Jui 0t i;.t.g"t:i' .t7:Vt-y.
Signature of Orvner/APPlicant
APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: UNdCr PCNAITY Of PCriUry, I.hCT.CbY CCTti$' thAt I hAVC TCAd thiS
application and state that the information herein is correct and I swear that any information which may hereafter be given by me in hearings before the
planoing and Zoning commission or the City council for the City of Rexburg shall be truthfirl and correct. I agree to comply with aII City regulations and
state laris relating tJthe subiect matter of this application and hereby authorized representatives of the city to enter upon the abov_e-mentioned property
for inspections purposes. NbrB, rhe tuilaing offiaa may rerrok" " permit on apiroval issued under the provisions of the 2003 Intemational code in
cases of any false statement or misrepresentatioi of fact in th. "ppli.ution or on the plans on which the permit or approval was based. Permit void if not
Jrzl/
-/ -/
DATE
/"3
WARNING_BUILDING PERMIT MUST BE POSTED ON CONSTRUCTION SITEI
plan fees are non-refirndable and are paid in frrll at the time of application beginning lggsg.-L m5
City ofRexburgrs Acceptance ofthe plan review fee does not constitute plan approval
{,*Building permii Fees ar. drie at time of application{* xBuilding Permits are void if your check does not cleadet
Routing:
13 00170
925 Widdison Ln - Deck Addition
Ted Dye (Please review by Monday, May 6)
Current Status
VH
{r
I
!
Please complete the following:
!
!
n
Review Plans
Enter Notes in the checklist under P&z Review in the workflow
Enter Notes in the Checklist under Building Review in the Workflow
l
{
!
Update the Result
Stamp Job Site CoPY as APProved
Return building plans and this check list to Amanda Saurey
Notes:
!
!
!
0sl02l13
PROIOSAL & ACCEPTANCE
Customer lD
Date:
hvoice #.
Time:
PO. Box 308 Rexburg, tdaho g3440
Ph. 656-0128, ffie ftpEffi*aa_
n-f' , >',c -{2 ^\ ,, A
R# RCE-1771
E-Mail:
n\t
Jou wame: J0hd P,lrg{ iaf
Home:
Work:
n .r I t -Cell: Jr\ -ltl(2 \
-
Fax:
We here by submit specifications and estimate for:
r', 1 -
Job Address/Location: /{{{A U r I
ooo,."", 905 lal
CiV Srate * r,0,
\ca--'
925 Widdison Lane _Deck Addition
copy
U.L)
i{ic r,.;0,
. l-.' isT,
REVIETA/ED FORCODE COMPLIAAIi
3oit ,5c 7o ll c E ,i
& /t'.,u
U^/L4 €Jf
Customer is responsible for:^L-t.l Markingsprinklerandpropertyrines-(customvinyr isnotresponsibreforunmarkedsprinkre^andrherewrttuea$15_0ochafgeperrepair.)
2. Obtaining and Fying for necessary building pemits as required for city and county codes.
Hi'lffi5"fraancewittrtheaboVespecifications'Payab|einfu||uponcompletionofjob.oras
1,.[t"iilig:f;,3{lffi i,t7,:,i&::,irs:ITl:3f "ontigent.upgnstrites,.cciJ"nitoii"rli'"'tnrtarebevon.rn,r^^hi"^r,]1.YI1l"^":ry.nextrachargeoverandj[,*"ir,.-"=i.1=t".n1'E![:1.:"tjlfrXiqq'#ff"iff:i,'#*"#,";flflil#:#tffii:x;::;?fi"3ilJ:[",Tgill':]ff:3::ilJff::"*"::$i:hi':g",
BY US IFNOTACCEPTED WITHIN-DAYS.
---? <i.. ^,, o .'t;,;f{*r,:4ai
lorized Signature:
***o'p:".""
.Ire
IPTANCE OF PROPOSAL:
S1+E,r-o '1 6rLl*t'tt.
Date: l- zs-t3
apPlication.
-Certificate
of g
sure that a cerl-- - ---"-.-- --. -.- -
- Identification Number-
ri[?i:|ji,illJ *n. o;ir,nul notarized application. Faxed or emailed copies of an apprication will not be processed'
rf you are registering as an individual person, your first registration-will expire on your next birthday plus 12 months and must be
renewed annually to allow continued practice. A renewal iotice will u. r"ti-"ppiolimately o weeks piior to the expiration date to the
mailing address you proviae. railure L notiff the su..uu in writing or*v-li'ulg" of name or addreis may result in you not receiving
t"r.*"'f forms oi othir correspondence (lC 54-5214')
@equires.thefollowing:rlo/a\ann|icnntMt]STt(zeomptete section lb-;", 6-;;fifi" "ppfi"",ion. Per-Idaho Code 54-5210(a) applicant MUST have an Employer Tax
#:"i;::;1,f.i,"*ri.3;93;ompensation insurance in the name of the business applving. You mav also submit i'writing a statement
- of exemption per rc 72-2.12. Make sure that a cerlificate of insuranc. o. u ,tut.rn.nt of exemption from such coverage is
,^ryfi||1":T::Hlilfiiiilinrurun.., minimum coveras€ amount $300,000.00, in the name of the entitv applving' Make sure
*;i;t;;ificite of insu.un". it provided with the application'
_aii";;;;r;';;;;lt";;t name and insured name match one another exactlv.
_ Mail or deliver th" o;;;;l 'otarized applicaiion. Faxed or emailed copies of an application will not be processed'
If you are registering a business entity, the original registration will.expire I 2 months from the anniversary date of issue' A renewal
notice will be sent annually approximatelv o *""[, pfior,o,rr. expi'ation dut. to the mailing address you provide' Failure to notify
the Bureau in writing of any change of name or addiess may resuli in you not receiving renewal forms or other corresponde'ce (IC
s4-5214.)
If your answer is yes to question 10, 11,-12, or. 13 regarding discipline or previous criminal charges, you will be required to
provide additional inrorn,ition. Any additional papeiwork necessary concerning such matters must be provided by you' The
additional paperwork may be submitted with the originar application or may be inailed, faxed or emailed after submission of
your application to our offices.
Entities and individuals may have other requirements for doing business in the State of Idaho includin-g registration wittt tfte
secretary of State,s office. please consider "o*uiilngirt" s".i"tuty of State's office as part of your contractor Registration
p[ocess.
Laws and Rules governing this occupation can be viewed at www.ibol.idaho.gov under,the contractors link. please be sure
to keep a copy of this dii;i r" fbi your r"cordr. There is a $20 fee for returned checks.
' security number.
.-it in writing a
n is provided with the
lual applying. Make
IBOL-CoN-APP-I 1l/12
I of 5
STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
700 West State Street' PO Box 83720
Boise, Idaho 83720-0063
APPLICATIONFoRCONTRACTORREGISTRATION
I hereby make application for registration as a contractor in Idaho *d;t ti; ;*isions sf ritle 54; Chapter 52' Idaho code:
please {ill out either the individual registration or the business entity registration'
INDIVID'AL REGISTRATI'N: use this section if you nr" rrut.r?uip"r"otr operating as a sole proprietor with
or without an assumed business name'
La. Name of Individual "nO tft" DBA./Assumed Business Name (if applicable
infomration listed above'The registration wlll be lssu
2a. Business Address '
(This is your Address ofRecord and is public record)
ztpCity
3a. Mailing Address-
(This address is noi public record)
4a. Business Phone ( ) E-mail
5a.DateofBirthSocialsecurifyNo.l/$73-122,I'C.requires'a|lapplicantstoprovideaSSnunrber
"-1ui?6u HA'E coMpLErED rHE sECrroN ABovE MovE to au"tTt:f u,
City zip
Street/PO Box
so.finn for busi: ng but not limited tu*rsr ENTIT' REGISTRATIoN: use this section for business entities includir
"ff
lfr"n';ffi ::"e*xf ll?il1,k',i;11,9,il1*,li;:ffi nL"J*DerFPnrylLr
name of the entitY'
The registration wlll be lssueo DearurB urs uuur'ra'v. I " ! . ,f) I
City
3b. Mailing Address-
(This address is not public record)StreeVPO Box City
4b. Business Pt orr" f)08)L5b-oU {E-man V \ n\l PYo )\ 4 t nnat I ,ri r,^
5b. Please complete one of the following:
A.Partneiship: FederalTaxldentifi^cati":l:PP"t'
(,rr*.j:*U;'*il;", "fiff::,'rfi::"ffiSll#jffidaa;Fa; o**'*r*ir Sociar SecurirvNurnbers in rhe
'pul.u.to*orattachaSeparatesheetofpaperifnecessary';r0tffi
Street/PO Box City
zrpStreet/Po Box
zipStreet/PO Box
CityStreet/PO Box
(Continued on next Page)
zip
2of5
principal offtcers and directors')
Atl.
Street/Po Box
APPLICATION FOR CONTRACTOR REGISTRATION
(continued)
B. corporation, LLC, LLP: , - - F.*r"l rax Idelti!111-o3-{u1P"' Xl"' -X?Ll t t }f,
(Ifyouareregisteringasacorporation,L!.C,",iiil,*.lclurBQ'DPb;i"*mdingthefullnanre
and address of each shareholder, officer, director, member, partner o. o*nF in ir-,e bu.iners 'amed. If a public corporatioti' list tlle
qqt)
Street/PO Box zipCity
Name
City State zrp
Street/PO BoxName
zipCttyStateStreet/PO BoxName
City Stat€zip
Street/Po Box
6. Do you have a current public works or construction manager license in Idaho issued by the Dt"itt"SLtitdi"c sfifrK:
Ifyes, you are not required to pay the $30 registration fee for this application. please attach a copy ofyour Idaho puEftc works or co{rstruction
;*''.ru:,:"ffi:'.:::::}i,,*"m*1i1l^:l".9*onlyonecategorythatbestdescribes
your business. This informati* i, urra to assist ttt" puuii" ing contractors for'projects')
8. You must hold worker's compensation rns'rance "'ry:.1:-q::T::":::t-?'^::],1#l:L,:;:i."trJi#"J#.T5?3o,Y""1",..*J:?r#il:l*X},]|:ffiH,IffiTiillili* t,,,,"'ce provider "o-p*v, the certiricate number, *a tr'' policv errective date'"';J:I^ i..,.,.:-.. e,^" r l.[u.r^,[,.J] T,nsur6\a ' bobAgg A-JfufuV-
Name
OR
S{o.\t lurw** g^*T (,Auc\d[ctl l*e*"tc loDb-bvv !-L--]-eU-
Insurance company Grtifi-"at" or policy # Effective date5
provide a statement as to why such coverage is not required under the laws governing worker's compensation ' (72-101- 230' I'c')
e. You must hold a general liabilitv insurance poli"v'o.{:ot,lt::*:1'-',t;*9^:l*::}l*;"tno":.:ut'attach the certificate and
enter the ;ilffi;;;;;ti;;p*i trt" ".ttificate number, and the policv effective date'
4?- tsF-rllq-l nE-+t-I' t-",^3-
Certifrcate or Policy # Effective date
As used below in questions number 10, 11, 12 and 13, the phrase "anyone with an interest in the applicant" refers to inclividual
applicants such as:'^.asoleproprietorships,withorwithoutanassumedbusinessname'
o and interests owned in or by a firm' partnership'
r limited liabilitY company'
o limited liabilitY PartnershiP'r corporation,o trust association
o or other entity or organization, or any combination thereof'
The phrase.,any jurisdiction" refers to "oy "ityr "oontyr state or federal unit ofgovernment' including ldaho'
(Continued on next Page)
IBOLCON.APP.I IIA2
Insurance ComPanY
3 of 5
APPLICATION FOR CONTRACTOR REGISTRATION
(continued)
i,l;,5l"r,lff "ppricant or anvone with an interest in the applicant ever been licensed ot t"sitt*"d*ffiffi1t t"ry
(If Yes, identi{ and list.belowwho }as been lice-nspd T::.ctj::lff'the
jurisdictio"trf P:t;"+';t;
Vltt f?eEti{rr.dtor,r.--FG"',' t^', B,,H,,Kt*n ft,,"kl{-'",tToo'ffi.'.,'ff#':;[hlHl]i'*'se or regi${ation denied, 11r. Has the appricant ": ":y:1:Yl:1i::,:T::',',i','i'J ;,I#ili"';;; "O y"' N No
surrendered oiotherwise suspended or revokedin any jurisdiction? , r:--,-!r-. r-^- ^^^r. i.orrinc orrrhnrirv r *1{
ifil:],::'ff |"?lilTJrii'l,i il?i,i,ii#;;; ;; ;'J.i".Juy the Board directrv rrom each issuing authoritv')
12, Tothe best of your knowledge is the applicant or anyone with an interest in the applicant currently the subject of a
pending disciplinary action or irivestigation ."r"t"o to engaging in the business or acting in the capaci$111f a contractglin any
iurisdiction?
iif V"t, identifo the jurisdiction and license/registration numbers')
No
13. Has the applicant or anyone with an interest in the applicant ever received a conviction, finding oJguilt' withheld
judgment or suspended ,"ni"n." for anv r'ronv in "nv
jurisdiction? .: "":::;-,":::";;:":
- f -\v"s NtNo
(If yes, please attach a detailed statement of "*pr*uiion do,o you, official court documents that include u\#tu'y of thel#tges'
the final order, a letter of status fiom your "u.r"nt proiuiiorvp.or" officer ifstill under supervision, , and any other relevant
information.)
AF'FIDAVIT
I hereby certify under penaltv of perjury that the.info''ution n'ouial,a*t:,'-t-*,:'-:"::::t:"i: tl"'r1i:1"rTn *ili:iic;:Hf["i'JJit*e1:lliiiii;:Tt#HnHH'ff?:"'dil;ii'?iqq;i";;***"i::::*.'::lgl,illll*,ig,:Ji'il1';;i;,il,'ff"*"Ji:;;l'"'i;Tlf":Tt:il"'"""J":ffi.il;;ffi;'5;"Ji'''ilffi;;;;;;';!r'" $91yTll'-:1l1':":1illo-lllli.,"93:l1:ffilli[],'Jlll",:;:::::r::TffH::::l;ffiJffi;;fi;;ffionir ri..n'"' or its authorized representative, any inron'atiou, report, record' staternerlt'
-^^-^^ ^rtl- rpcicrrarinn fnr which I am aoolving. I also[:'fr.;:#,ff,T:5il:iJ::i"ffi;;"""'iJ,|ffiH;;""'ffifif ;;F;nin." or'rc i"gi't.xion ror which I am apprving' I arso lrerebv
-^ aL^1 -^,, ^rLon'ica he nrntecfed or confidential to otherii,iililiifll'fl;STfi#ii:Til#ffiil;t;il;;i.';ppil4 *.{;e that mav othirwise be protected or conndentiar to otrrer
. ' ^--^ ^.,aL^-:--,{ +^ .icn rhis onnlication on hehalfofthe li
;:i$'i,:.n:,f,!:n]J:il:1ffiil:.TllT:ffi;:, ffi;;#i;:;;, i.*ttil;' r arn authorized to sign this apprication on beharrorthe ricensee'
-.---\ '?
Signature of Owner
State,qf , County
Subscri Ei'ffii*otn before me thi
. .,, trill ll I I t t 11rrr,
.iYS I 4
G
$sl:-t:$i
,,4,o,rr,
:
=--- -1=>t- rt
2rr,
eal)ilo iii.c ti
iJ -, '. -,"v^'...
i. Q, -.j
'. '/nl'.9.'-h".....:.....
'DAna .,\tarurl,i,'it'*N
7:z
',Az=
'Y--ss
'. {1im:zi-v
+i
Print Owner or Authorized
Note: Please print and sign your full legal name
Publicdfficial
my commission exPires
IBOL-CON-APP-I
4 of 5
oiQo'\--'CERTIFICATE OF LnBILITY INSURANCE
REVISTON NUMBER:
HI#t^itffJ?cArE HoLDER' rH rs
cER'FrcArE DoEs Nor AFFTRMA'VELv on-ire,iiiiv'ili 1l-t1".:i:Eljll:gS^iii::,I}5""?XE*tgi,i:tfl[???ftr]ltJ"StJgE8
8:i;l[:i;,:??'-t,X8lflFTftJt'i^'J4]!ir:l9i:i9il-'Jiiui'-'a coHrmcr BET*EEN rHE ,ssurNG rNsuRER(s]' AUTH.RTZED
iEFniserlirrtvE oR PRoDUcER, AND rHE cERTlFl
(ies) must f"' ""i9'::9
terms and conditions "rirt"-p.lity,-;;;i" policies may require an endorsement' A statement on
tf SUBROGATTON lS WAIVED, subject to the
this certificate does not confer rights to the
certificate holder in lieu of such
PRoDUCER State Farm InSuranCe
DuPont OPerations Center
Statetarm 1000 Wilmington DR
&. DupontwA98327
rNsuREo DeckprO LLC
4704 Lake Loran
Rexburg, lD 83440
COVERAGES CERTIFICATE NUMBER:
;-$-ffi;oFo"ERAttoNs/LocATtoNsrvEHtcLEs (AttachAconorot,nadittonat Romarksschedulo,ifmorespaceisrequired)
300.000
300,000
300,000
600,000
600.000
UVtsKArrtro vL'rilr 'v^rk '!Yrrr--'-' - I THE POLICY PERIODTHlSlSTocERT|FYTHATTHEPoL|c|ESorrNsunnHE|NsUREDNAMEDABoVEFoF
TNDT.ATED. N'TwTTHSTANDTNG ANy REQuTREMENT, renv-on cor.rDltgl'-9l nr'ri co*rnncr oR orHER D.CUMENT wlrH RESPE.T ro wHlcH THls
cERrFrcArE MAY BE rssuED oR MAY PERTATN, tiE-riHifiME-.tif,:,lg::-?I":Fi."i';tJt"1*T'"IrBED HERETN rs suBJEcr ro ALL rHE rERMs'
EiSJ,liJiJr'isi^fi'"4'dii6i,i #siitil boir6iii. Lir,,rrrs:siowr.r r'rnv HnvE BEEN REDUcED BY PA|D CLATMS'
ffi
93-BE-H247-4 F
COMMERCIAL GENERAL LIABILIry
.LATMS-MADE [-_l o""r*
GEN'L AGGREGATE LIMITAPPLIES PER:
polrcvl l:i-=i I lLoc
AUTOMOBTLE LIABILITY
ALLowNED T-_l SCHEDULEDAuros | | AqI.o^s.f l NON-OWNED
HIREDAUTOS I I AUTOS
BODILY INJURY (Per Person)
BoDILY INJURY (Per accident)
WORKERS COMPENSATION
AND EMPLOYERS' LlABlLlw Y / N
ANY PROPRIETORYPARTN ER/EXECUTIVE
OFFICE/MEMBER EXCLUDED?
(Mandatory in NH)
lf yes, describe under
TION
AUTHORIZED REPRESENTA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
iiii-ExpinartoN DArE iHeneor, NorlcE wlLL BE DELIvERED lN
ACCORDANCE WITH THE POLTCY PROVISIONS.
ACOnO COnpOMTION- All rights reserved
State of ldaho Bureau of Occupational Licenses
700 West State Street
P.O. Box 83720
Boise, lD 83720
ACORD 25 (2010/05)The ACORD name and logo are registered marks of AGORD 1001 486 132849.8 01-23-20
os/a6/2Ot3
208.356 .442020E.355.4411
-fenton@l eavi tt ' com
ffite rnsurance Fund
COMMERCIAL GENERAL LIABILITY
.LATMS-MADE l-l oc.r^
GEN'L AGGREGATE LIMIT APPLIES PER
por-rcyl lliCr I lLoc
MED EXP (AnY one Person)
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HTRED AUTOS
NON.OWNED AUTOS
BODILY INJURY (Per PeFon)
AND EMPLOYERS'LIABILITY V/N
ANY PROPRTETOR/PARTNER'EXECUTIVE
OFFTCER/MEMBER EXCLUDED?
(Mandatory In NH)
E.L. EACH ACCIDENT
E.L. DISEASE. POLICY LIMIT
ACORQ"CERTIFICATE OF LIABILITY INSURANCE
HE CERTIFICATE HOLDER. THIS
CERT|FICATEDoESNoTAFF|RMAT|VELYoRNEGAT|VELYAMEND,EXTENDoRALTERJHEcSJtrI"":'fr'j:"1?':?3l-I1i,i3:'$?3Eil[,1"iffi?Hi,}l,;?lH]'ffih*l.,#o&; rot "o*.t'trrE A coNrRAcr BETwEEN rHE rssurNc rNsuRER(s)' AUTHoRT.ED
nipneseNrnrvEoRPRoDUcER'ANDTHEcERTIFICATEHoLDER' ,:::=:=:::::::::i;=:::r:i::i:
rMt'uKrANr: rrtrrewlrrrr@':-:,",:: '::::^:;,^,::;^.; ; tementonthiscertificatedoesnotconferrightstothethe terms and conditions of the policy, certain policies may require an endorsement A stal
certificate holder in tieu of such endorsement(s)'
PRODUCER
Archibald Insurance Center
135 West Main
P.O. Box 95
Rexburg, ID E3440
INSURED
DeckPro, LLC
P.O. Box 308
Rexburg, ID 83440
|tiona|Rema'k3schedu|e,lfmore3pacelsrequ|red}
Owner (Shane Belnap) is exempt from Coverage
CANCELLATIONCERTIFICATE HOLDER
STATE OF IDAHO
BUREAU OF OCCUPATIONAL LICENSES
7OO WEST STATE STREET
, rD 83720
SHOULD ANY OF THE ABOVE DESGRIBED POLICIES BE CANCELLED BEFORE
THE ExptRATloN DAIE inEnior, NorlcE wlLL BE DELIvERED lN
ACCORDANCE WITH THE POL]CY PROVISIONS'
REPRESENTATIVE
@
ACORD 25 (2009/09)The AGORD name and logo are registered marks of ACORD
At rights reserved.
TNSPECTION TICKL
O/nug.Plumb' D
Inspcrion Requesr: Rec'd By 1 {'""''''u -',** frffi< i,. ,,'l);aitt,-f., PhoneNo.
Req. By ) r (k ' LL
bt - !. Do,.nir Nni,it *i,'u;;*;' !r'''"errnir No' -:::
lnspection TYPe
Day /Time Req'
0 comm'
lnsPector's RePort
:ffiowcs ,8Y CN flN/A
':,>''l /lG
(..r;- / / ll"t't
Res.
f] DISAPPROVED
N NOTAPPLICABLE
lqhxnrb oro Nor lNsPEcr
Rec't Ackmrwledged
t{?itc 'Olicc Cogt
F.f rR.ClXl3
PH - lnca..F.toott
tblos . Job CoPY
l
t City of Rexburg ReceiPt#: ltl0
Hre:5f2l20l3
IdlArurtDrcTdlPrfrcrt:
Codc REXBURG-RccPil'10-2-5-2013-anadas
ls&52
15&52
Pacr I of I
RcceivedBY: oa&s