HomeMy WebLinkAboutALL DOCS - 12-00124 - 5383 S 1650 W - Firewise Annual CertificationoI
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Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022
CTT'Y OF
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Am eri cai Fami ly Coffi ffi u ni ty35N l.tE
Rexburg, lD 83440 www.rexourg.org
*A toftu ystem certfication perzit is required to install, nodtfi, maintain, or sentice all new and existingfre
extinguisbers,fre suppression ystens,fre alarm slstems, and otber lfe mfe4t sltstens within the Ci4t of Rcxburg"
BUSINESS NAME: Prvvw15€
OFFICE ADDRESS z 5 +t + 5. ioru ,v ^ t\*xw; Bir to 6t++o
OFFICE pHONE NUMBER: 2et '2p t - t o G'u
CONTACT PERSON: TEEUI ru RtC T S CELL PHONE #:'7W Zct 'ru a z
PLEASE IDENTIFY SYSTEMS TO BE COYERED BY THIS PERMIT. CHECK ALL
THAT APPLY.
FIRE ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level 1
Cetifi cations or equivalent.
{. PLEASE PROVIDE, CE,RTIFICATIONS:
{.NICET Cetification
*Panel Certification
f.Proof of Liability Insurance
*NICET Level II tequfued for design work
AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a
minimum of NICET Level I Certifications or equivalent.
{. PLEASE PROVIDE CERTIFICATIONS:
*NICET Certification
{. Any Additional Certifications
.i.Proof of Liability Insurance
{. NICET Level II tequired for design work
X-"r*" E*TTNGUT'HERS
{.Proof of Certification & Ttaining
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
trProof of taining for commercial cooking heads
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
-SPECIAL HAZARD SYSTEMS
FIRE PUMP
4.*E'PIEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS,
I^{STAL-LA.TION CERTTFTCATTOL{S, LTABILITY TNSURANCE, ETC. FOR ALL
DISIPLINES***
I certi$ that I have tead this application and declate undet penalty of periury that the information contained
hetein is cottect and complete. I agtee to comply with all city otdinances, adopted codes, and state laws
telating to the installation, modification, service, and maintenance of new and existing life safety systems. I
heteby authorize teptesentatives of this city to inspect any work fot compliance purposes. I am either the
contfactor tesponsible fot the worh ot I reptesent the ownet as signified above and am acting with the owner's
/conttactotts full knowledge or consent.
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PRINT NAME OF APPLICANT
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PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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Receipt Number:
35 North 1st East / Rexburg, lD. 83440
Phone (208) 359-3020 / Fax (208) 359-3022
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Base Fire Fee
CREDIT CARD
genpmtrreceipts Page 1 of 1
rage 1 of 1
March 21 ,2012
lnsured: Firewlse, LLS
53B3 S. 1650 W.
Rexburg, tD 83440
Policy is effective trorn 12:01 AM A3.nUlz to 12:01 AM 0AtiC/1t.
Agenh Kraft Lake*Forenpost lnsurance Group
PO Box 3278
Grand Rapids. Mt49501
i
This is to certify that the undersigned have procured insurance as hereinafter specified from certain lnsurers. Insurancedescribed herein has been effected. against wtrich a Certificate(s) and/or Poficy{ies) will be issued and in the event of anyinconsistency the terms, conditions and provisions of the Certificate(s) and/or rolicy(ies) shall prevail.
Company Century $urety Company (pEN)Assigned Policy S CCp 757667
Coverage:PFR RAMP QUOTE BO974O
Binder is effective from 12:01 AM 03116112 to 12:01 AM 06116/12, unles$ cancelted or reptaced by the poticy
Premium $ 1,314.00
Policy Fee 100.00
Insp Fee 150.00
State Tax 23.46
Qlamp Fee .Q",-91Total $ 1,591.37
$578.50 is the Minimum Amount retained if cancelleb.
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NO FLAT CANCELLATTON$ i
Insurance under this Binder to ccase al the last above..named date.at the place of location of risk insured, or at such time prior thereto asthe Certificate(s) and/or Policy(ies) may be issued on tne auove rist<, bi uriless pievl,iusf y canCeii,i<i i" ilitii,Sl
Please review carefullv as the. coverages offered may differ from tho$e requ€sted in your specifications. Should there be any questionscontact this office imm-ediately.
- I ' ver vtsvvrr'vv'v
The Undersigned are not Insurers, however, lnsurance has been effected by JH INSURANCE SERVICEST
Remarks Thanks again for the businessl
Dated at: Sandpoint D, AU21l12 JH IhISURANCE $ERVICES