HomeMy WebLinkAboutALL DOCS - 12-00123 - Nelson Fire Systems Annual Certificationa
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35N I'tE
Rexburg, lD 83440 www.rexburg.org
RexbUrg-Mqdison Counly
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022
REXBURG
Ameri ca's Fam i ly Cttmmuni ty
*A safe4t gtsten certfication pemtit is required to install, nodfri, mainlain, or seraice all nea and existingfrvextinguisberc,fre suppression ystems,fre alarm gstemq and other ffi safery slxens witbin tbe CiE of ilxbury"
lt I r
BUSINESSNAME: Nelson l:"n S,r.-t"^s Dn.^^'.r 2 - rtalLcl:
oFFTcEADDRESS, lLl 6l fl"of 9"{rqe'*q( 81 tt E
OFFICE PHONE NUMBER:$ot- ,t 6fr -g3oo
coNTAcTPERSo*, B"n A/ukon 6ELLpHoNE#: /Ot- 6Se-7?qO
PLEASE IDENTIFY SYSTEMS TO BE COYERED BY THIS PERMIT. CHECK ALLTHAT APPLY.
"xrrnn ALARM SYSTEMS - Alarm conttactots shall haveaninimum of NICETLevel 1
Certifications or equivalent.
* PLEASE PROV IDE, CE,RTIFICATIONS:
{.NICET Certification
.!.Panel Cenification
*Proof of Uability Insurance
{.NICET Level II required for design work
AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have aminimum of NICET Level I Cetifications or equivalent.
' PLEASE PROVIDE CERTIFICATIONS:
*NICET Certification
{.Any Additional Certifications
*Proof of Liability Insurance
* NICET Level II required for design work
FIRE EXTINGUISHERS
i.Proof of Certification & Training
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
iPtoof of ftaining for commercial cooking heads
-STANDPIPE SYSTEMS _SpEC16f ffAZ^1RD SySTEMS
-SMOKE CONTROL SYSTEMS FIRE PUMP
*.{.T<PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,IIVSTALI-4TION CERTIFICATIONS, LIABILITY INSURAATCE, ETC. FOR ALLDfSIPLIIUES*{c*
I ceti$' that I have tead this application and de.late undet-penalty of periury that the information containedherein is couect and completel i "g... to "ompty with all "6;;;il""ces, adopted codes, and state lawstelating to the installation, modific"atio*r, ."rui"., and mainten"o.. orr,"* and existing life safety systems. Ihereby authorize teptesentatives of this "igi" inspect any work for compliance putposes. I am either the
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PRINT NAME OF APPLICANT
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PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.**********************************{c*************rF***************{.x
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TRAYELERf
LISTING OF FORMS, ENDORSEMENTS
THIS LISTING SHOWS THE NUMBER OF FORMS,BY LINE OF BUSINESS.
POLICY NUMBER: 4T-co_6063Ns83_rND_1 1
EFFECTTVE DATE: 06-0i -11
ISSUE DATE: os-26-1i
AND SCHEDULE NUMBERS
SCHEDULES AND ENDORSEMENTS
IL
IL
IL
IL
TO 02 11 89
T8 01 10 93
TO 01 01 07
TO 03 04 96
COMMON POLICY DECLARATIONS
FORMS, ENDORSEMENTS AND SCHEDULE NUMBERSCOMMON POLICY CONDITIONS
LOCATION SCHEDULE
CONTRACTORS
COML GENERAL LIABILITY COV PART DEC
DECLARATIONS PREMIUM SCHEDULE
KEY TO DECLARATIONS PREMIUM SCHEDULETABLE OF CONTENTS
COMMERCIAL GENERAL LIABILITY COV FORM
ADD'L INS-ENGINEERS, ARCHITECTS, SURVEYCAP ON LOSSES-CERTIFIED ACTS-TERRORISM
AMEND_NON CUMULATION OF EACH OCCDESIGNATED PROLIECT(S) ECru AGGR LIMITWEB XTEND - LIABILITY
BLANKET ADDITIONAL INSURED (CONTRACTORS)
CONTRACTORS XTEND ENDORSEMENT
FUNGI OR BACTERIA EXCLUSION
EMPLOYMENT-RELATED PRACTICES EXCLUSION
EXCL-CONSTRUCT MANAGE ERRORS & OMISSIONS
EXCLUSION-CONTRACTORS-PROFESSIONAL LIABEXCLUSION-SUITS BY ONE NAMED INSUREDMOBILE EQUIP/EXCL VEHICLES SUB TO MV LAWEXCLUSION-PROJECT SUBUECT TO WRAP UPEXCL - ARCHITECT/ENG/SURVEY PROF SERV
EXCLUSI ON-LEAD
EXCLUSI ON_DI SCRI MI NATI ON
AMEND-POLL EXCL-INCL LTD COV POLL COSTSEXCL-EXTERIOR INSULATION & FINISH SYSTEMEXCLUSION - SILICA
EXCLUSION WAR
EXCLUSI ON-ASBESTOS
EXC-HAZARD-CONNECTED DESIGNATED EXPOSURE
UTAH CHANGES
GENERAL LIABILITY -
-
cG TO Ol 11 03
cG T0 07 09 87
cG TO 08 11 03
cG TO 34 .tl 03
cG o0 01 10 01
cG 20 31 07 04
cG 21 70 01 08
cG D2 03 12 97
cG D2 11 01 04
cG D2 34 01 05
cc D2 46 08 05
cc D3 16 07 04
cc D2 43 01 02
cG D2 88 11 03
cG D2 93 11 03
cG D3 07 11 03
cc D3 22 01 04
cG D3 56 01 05
cG D3 91 03 07
cG D5 46 12 09
cc Do 76 06 93
cG D1 42 0't 99
cG Dl 73 't1 03
cG D2 04 06 01
cc D2 40 06 01
cG D2 42 01 02
cG T4 78 02 90
cc T4 81 11 88
cG 0't 86 12 04
INTERLINE ENDORSEMENTS
IL T3 68 05 10
rL oo 21 09 08
IL 02 66 09 08
FEDERAL TERRORISM RISK INS ACT DISCLOSENUCLEAR ENERGY LIAB EXCL END-BROAD FORMUT CHANGES-CANCELLATION & NONRENEWAL
lL T8 01 10 93
Cfient#: 1fl7o nerlr
\NCEACORD,"CERTIFICATE OF LIABILITY INSURANE DATE (MM/DD/YYYY)
3122t2012THls CERTIFICATE ls lssuED As A MATTER oF lNFoRMAron oNr-v nllo coNreRs r.ro RtcHTS uFoil-rHE cERTtFtcAre noloeRffiisCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTTUTE A CONTMCT BETWEEN THE |SSUING TNSURER(S), AUTHORTZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
IMPORTANT: lf the certificate holder is an ADDIi
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
CLIFF ORTON
COBB STRECKER DUNPHY & ZIMMERMANN
5 TRIAD CENTER SUITE 340
SALT LAKE CITY, UT 84180
FXffIi"' NANCY OLIVER
l'l8"N.o, E,r), 801-532-5975 | lil. no,, s01_53t.746S
F-Jffi !r. noliver@csdz.com
INSURER(S) AFFORDING COVERAGE NAIC #
TNSURERA sT PAUL FIRE & MARINE INSURANCE
INSURED
NELSON FIRE SYSTEMS
BEN NELSON DBA NELSON FIRE SYSTEMS
1469 SOUTH MAJOR STREET
SALT LAKE CIW, UT 84115
rNsuRER B, REPUBLIC INDEMNIry COMPANY OF C
INSURER C :
INSURER D :
INSURER E r
INSURER F ;
COVERAGES CERTIFICATE NUMBER:REVISIONNUMBER:
TH|S|STocERT|FYTHATTHEPoL|c|ESoF|NsURANcEt-tsrEoeE|bWHAVEBEEN|ssUEDToTHE
INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITIONOF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE 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 PAID CLAIMS.
LTR
A
rYPE OF INSURANCE POLICY NUMBER POLICY EXP'MM/DD/YYYYI LIMITS
Tl "o"rr*a,o,- GENERAL L,ABrLrry-f-]
"*'rr-"oo. fx] o""r*--t---
co6063Ns83 ,6t01t201106101t201tEACH OCCURRENCE $ 1.000.000
BAYfiP"E'J?.EEJIF.B.$300.000
MED EXP (Any one oerson)s5.000
PERSONAL & ADV INJURY $ 1.000.000
__l GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER;_l ,o,,"" l-i]",5+ l-1,-o"PRODUCTS - COMP/OP AGG s2.000.000
A AU'
T
T
.OMOBILE LIABILITY
ANY AUTO
ALL OWNEDAUTOS
HIRED AUTOS
l--l SCHEDULED
L-J AUTOSI v I NON-OWNED
l 4 ] Auros
II
8A6063N583 ,6t01t201106101t20'ttCOMBINEO SINGLE LIMIT(Ea a@ident)1,000,000
BODILY INJURY (Per psFon)
BODILY INJURY (Per accident)
PROPEIiIY DAMAGE(Per accidentl
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
EACH OCCURRENCE
AGGREGATE
DED I Rererrroru s
B WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORY'OA'ruE"C*'""'U' 14oFFtcERyMEr\4BER EXCLUDED? tXl(Mandatory in NH)
lf yes, describe underDESCRIPTION OF OPERATIoNS below
N/A
18182101 ,7101120110710112012v IWCSTATU- | IOTHA ITOPVIII,ITQ I IEo
E,L. EACH ACCIDENT s100.000
E,L. DISEASE - EA EMPLOYEIs100.000
E.L, DISEASE - POLICY LIMIT $500,000
DESCRIPTION oF OPERATIoNS / LOCATIONS / vEHICLES (Attach ACORD l0l, Additional Remarks Schsdule, it moro space is roquired)ANY & ALL WORK PERFORMED BY THE INSURED.
MADISON FIRE DEPARTMENT
26 NORTH CENTER STREET
REXBURG,ID 83440
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED tN
ACCORDANCE WITH THE POLICY PROVISIONS.
@ 1988.2010 ACORD CORPORATTON.
NEO
ACORD 25 (2010/0s) 1 oj ,l
#s452884/M420345 The ACORD name and logo are registered marks of ACORD
All rights reserved.
[:TY CF REXFURI
FAIIT fit: HtLgfH FIRS SySTESS
ITATE:03/19/1t
TIi'{E: S?rlTrII
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ReceiptNumber: 1f4fi##,ltl#'=t*
i BF TIRE FTRiITT LIilNEFi :
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FAYIIE}IT
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pEF:i{IT $ 1: fifflt3
THAIiii TNU Ai'tII HAI'T A ilIrjT II'IY
t'1s /0419,/ci'iTR
ftE[tIfT ililr 148S63
REF N0: 11060
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D. 83440
208) 359-3022
$ 100.00
$100.00
$100.00
Total:
$100.00
$100.00
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