HomeMy WebLinkAboutALL DOCS - 12-00131 - Ace Fire Annual CertificationaI
U
1
H
E
(n
a
E
H
o
E
N
F]
H
4
Ho
F]
Hcz
A..()
FD @O
F t'.lfn
O -l -'.
hdo;
FD
=; RP
-' ts r'{
Ct u'Ho '*)
g't o
@FD 0
CP rr. FD
lFF H)
ooT9 .T
tr
H
N
H
le Fl
O :sh
H Ht9'T9
Av
c
H
ct?
H
!. l*i :X'N
J. |..r{t Lrl r^frX:
* a, l-{ a
Ff LA{ *
nf-lne
F i-.4 iI1
f 't\J
rn
€ t.r J
Rexburg -Modison County
Emergency Services
Phone: 208.372.2326
Fox:208.359.3022www.rexburg.org
c r't'Y 0 I
K.EXffilIRf;
Alneriid! l:tlnri\' (tliil ilj U tt I t|35N I'tF
Rexburg. lD 83440
"A tolitJ ytstem certfrcation perwit is requircd to install, nod{y, maintain, ar seruiu all new and wisting-frrc
extingaishers,frc supprssion ystens,fin alarm sjstenso aad other lifa saJbSt ystens witbin the Ciry oJ'Rtxburg"
BUSINESS NAME:Patcel:
OFFICE ADDRESS: l35i jt/ nt <T 9ll (.ha,-Aer/tt.n
/lEt-ErU4 lnT
OFFICE PFIONE NUMBER:
coNTACT PERSoII: EJ./1LaTTHENS- CELL PHONE *.K@1JXT"SAI
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECK ALL
TH/t'T APPLY.
*_FIRE ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level 1
Certifications or equivalent.
{"PLEASE PROVIDE. CIIRTIF,ICATIONS:
+NICET Certification
t Panel Certification
t'Proof of Liability Insumnce
*NICET Level II required for design wotk
*_*-AUTOMATIC SPRINKLER SYSTEMS * Fite Sptinkler Contractors shall hzve a
minimum tif NICb,T l,evel I Certifications ot equivalent'
.'1. PLEASE PROVID hI CER f I}. iCA-f ION S :
{.NICIIT Certification
*Any Additional Cenifications
'l.Ptoof of Liability Insurance
* NICET Level II tequired for design work
, l I
'
*rlut*" EXTINGUIsHERS ,,,( -.t.7,gr. ( i " /LisL llstfr/
*Proof of cemification&Ttaining 'lu(g'l'21-Ytrsv' (Lro^ - '
V_AUTOMATIC FIRE, EXTINGUISHING SYSTEMS FOR COMMERCIAT
COOKING
8Prcof of training for commercial cnoking heads
STANDPIPE SYSTEMS
-
V SPECIAL HAZARD SYSTHMS
ida.fu tra'tls lD
SMOKE CONTROL SYSTEMS FIRE PUMP
{d.*PLEASE PROVIDE DOCAMENT'ATION OF TRATNING LEVELS,
INSTALIA,TION CERTIFICATIONS, LIABILITV INSURANCE, ETC. FOR ALL
DISJpLINES***
I ceci$ that I have rcad rhis application and declare under perralty of petiury that the information contained
hereinie coffect and complet*. I "gr". to comply with all city otdinances, adopted codee, antl state laws
relating to the installation, modification, $eryice, and maint€nance of neu/ and existing life safety systems. I
hereby authorize tepresentauves of this city to inspect any wotk fot compliatrce purposes. I am eithet the
contractot responsible for the work, or I reptesent the owner as signified above and am acting with the ownet's
/ conttactafs full knowledge ot consent.
PRINT NAME OF APPLICANT
3-r.).^ /?\
DATE
PERMIT YALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
******rf*{.rNcllolc{o*{<****rl.J.*********rl.a45a:fF*{olc*******:{.rt *rf***t t{rtl.rl.******,hfi***,f****{.****
AFPLICANT'S SIGNATURE
-2"
Glient#: 25511 OLSONENT
ACORD*CERT|FUTE OF LtABtLtTY tNSUilNCE DATE (MM/DD/YYYN
6t14t2012THIS CERTIFICATE lS ISSUED lS A n4arren Or TTFORMAT|ON Ol.tLy ANDCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE |SSUtNG INSURER(S), AUTHORTZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificate holder is an A
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 anrloreemontrcl
PROOUCER
Montana International Ins.
A Member of Payne Financial Group
P.O. Box 6127
Helena, MT 59604-0638
gUNIAGI
NAME:
lu'"r"u, i l#, n
E-MAIL
ADDRESS:
INSURER(S} AFFORDING COVERAGE NAIC #
tNsuRER A: Seneca Specialty Insurance
INSURED
Ace Fire & Life Safety, LLC
1353 Elm St.
Helena, MT 59601
lNsuRER B. Assoacated International Insura
rNsuRER c , Continental Western Insurance C
INSURER D:
INSURER E :
INSURER F;
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
THIS ls ro cERrlFY rHAr rHE PoLlclES oF INSURANCE LISTED BELoW HAVE BE-NISSUEDToTHE-IN-mED NAMED ABove ron rxeffiFEldINDICATED. NOTWITHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTMCT OR 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.
-TR TYPE OF INSURANCE NSR ,t vD POLIGY NUMBER POLICY EXPIMM/DD/YYYYI LIMITS
A
Tl
"orr.*",o1
GENERAL LrABrLrw
l_l .LA'M.-MADE l-xl o""r,--f--
J-
8AG1008796 10t16t201110t16t2011EACH OCCURRENCE s 1.000.000
BAHfiEEJ?.ltlJ'Fo.*.'$100.000
MED EXP (Any one Derson)$5,000
PERSONAL & ADV INJURY $1.000.000
__.J GENERAL AGGREGATE s2,000.000
GEN'L AGGREGATE LIMIT APPLIES PER:_l ,o,-,"r 1-l tsP; l---l,-o"
PRODUCTS - COMP/OP AGG s2.000.000
c AU']
X
T
OMOAILE LIABILITY
ANYAUTO
ALLowNED f.l scneouleoAUTOS L_J AUTOSI v I NONOWNEDHTRED AUrOS | 4__] auros
tt
cwP236010228 101011201110t01t2011L;(JMtsINtsIJ t'INGLE LIMIT(Ea amidentl c1.000.000
BODILY INJURY (Per pe6on)
BOOILY INJURY (Per accident)
PROPERry DAMAGE(Per a@identl
B x UMBRELLA LIAB
EXCESS UAA
X I occun-l
", o,^r"-rro..
cu8w3650411 10116t201110t16t2011EACH OCCURRENCE $2.000.000
AGGREGATE $2,000,000
oeo I Xl nerer.rrrolrs1000O
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANy pRopRrEroR/pnnrruervexecurve 14OFFICER/MEMBER EXCLUDED?
(Mandaiory in NH)
lf ys, desibe underDESCRIPTION OF OPERATIONS below
N/A
WCSTATU. I IOTH,TORYIIMITS I IFP
E.L. EACH ACCIDENT
E.L. DISEASE. EA EMPI OYFI
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERAIONS / LOCATIONS / VEHICLES (Attach ACORD 10'1, Additional Remarks Schedute, if moe space is required)
CERTIF]CATE HOLDER CANCELLATION
For Information Purposes Only SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
c Q11fi4*
@ 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 2s (2010/05)1 of 1#s7a418O1M775114
The ACORD name and logo are registered marks of ACORD
BA{
ooz
TT
O
tn
F{Fz
:'i
q
O!u
F
Etrt{
?
14
o,
tT(.}t&
fi
w
o)CD
I
*r
(O
,q
FX
*I
Io)
q-)
rqxztrtlct <HHt:z
--\J
Hr{bvz.Z
F(}
\J \<
Fq tu
H
ffi
s
s
ffi
ffi
s
ffi
s
rr17.
Y'1
m
L,J
tit
b
It
7
}"
}"
--t
n
\t-..
L\
1I{
"fur1
h"rit
tFIt
-)
F-E
FT
-:
:UF
4
!s
Eo
x-
€
rng
S
F\5a.
l-oo
=a)
F|rFl.\Uo
€6
c-
I
g+ =
Efi 7Et dq8 r
sd 5oa' IPo b\a +AEg E
$$'-gfl i=+${ l"E i e A g
S:=; r I i 5 e *q=r-e;p = iE
*g$iEE rs
lESi,rl-
il*q FEd. €'+\.J\\oa- =$s $5E- F
fl$ "ss
--l.\'@6ot \'
S.atE-ffi|l$i{\Ht a
lk tn-l *51
tLt f .t tnrt =.
lfi"Jr+rgll )Xtffir I tF,+tltffi-rffil
rna*il
ai =.
d.Qrb
bEArO
o
ss
oos
(d q)
.9 .9
N) t\)oo
s.{
b\
G
CA*t
d
o
h
+a\-
F
h
F
rF\
n
6o\AJ\d
t
s
-o Rom 6cco-\6
t Fs = 8 F r us'= I ys 6- f 3='=o=:-==r-,io=>Aooi\r f ? f]R I XFSoa* lF+Q o r- o o!qo@-riaab(ai3.'Tl=r
:f!+:='S-L=;!J-4,=+5 i f.n 5I +o)d o^ $ -Fq ar\; B.='3= ?_o o." =.i \r. = a::
4vr (D-oq6 ^:a!.D*(,. 3d6' -o
o5 d
aoh o
q.
oo,
o)
o:t
-O
l\)
5
tFE=8F6d='= 91 Vl 6- f p=.iiTi<45=rd3?iH-'EseE;6{ 3 *
9db'-. 6"9!D(D(,-T-(/|" to'=Q. rr9r:+!' ='f,_a.l o
? f +-d I or'R= o) -;
:+:ri'; B.='3=o o." =.-1_ - /n Jr v),.
n-4v(D-o
v dqs srcio' Eo=o-aox o
I
mxtt
qi+o
Uq)
(D
0)a
L
.tr
bo
\
€
xo5\\)o
F}.\Ito
ano5
rne<d3* dq8 -
sd =o6' *Po b\e +qEg s
N$a dls
sil.ist i=
S eo $ l.E I e d' fg =1€ =fi I q j e
$ttil;'E i1E
*dsld-: o
iESir?'.6'si i-s$* h'E i5. €',+\-J\\og 5
$F $
6\. 6'
66 aq3 -5a-
h
sil
qt ='
6.4so
UE$o
o
$o)
5S
(d o)-o ,9
\) \)oo
+.{
o'
h
op*6
o
b
b
*
fa
3o
rn{c)
(D
OJ
o
I
a)
o
o.:\
it
='
!a
cno
oa
-oom
a
@bo
ffi
urslcnxQ==r's$rnc--.YrvOa-s i: gE a€ E + I$.i*;xF3 ilss pB E 2F a lFil=3+3 EEq f96S r*-;q)r_+L.=+
->F.OJta!+FiHi=B il
99=orS- tssBggl= s-;"; qPr ]
33 :ilAA a=*ffI a6-d i\FT
:a
g"+
$=.
6.(a30
UEArO
o
$o)
N.l\)
JO JO
N) r\)oa
s.{
rng
IJ
F\\{a,
f-oo
=s)
F|\
F|\\Y'o6
\T
h
O -.{
i* =€8 eE+ frg,R' =sd 2\ud' =$s^ a=o e.{ lL=
N q$ [dn
sttitE is
$cgF r i s i g
*+=ins: ? o x
suiEgfi= iE
iB$efr; o
f-U$=esd 8s
+\a aSS' Tog 3eS. Igg o5N. E
66' e
QSd'5
b
!x'
\
os*x
o
h
F*sa
o$
Eo
x-\
Efn
a)
o
oi
d
I
q)
Qo'\
ll
U)o
o
@
IOom
o
@bo
lffiFE'ltruJ>ffilffiffi
:]rcn:xQrzX;'l fi--9(! 0 (DS: gE 6€ E + =.i'p X.o='d -o !DQ^)XmR- i+ob U 2{ =:Fre=3 qB
Fe 6 S: + s
fY.LT5(D- f o =Q>X f ogi?=o
Q5.-l\i,RdtDS=co '- f. i-i =. -{.(.oUJ
N)aC
= -oi
ilTl A
6-d €>
vk
fd-o
q
mx
!
OJ
o
Uo)
o
O)
o5
N
i,
A
bo
\
€
xo55oFf,\tl
o
qo5
$* =a8 IE+ ftq,$' =sd 2:1 a -6
5;u r-=
$ qs 5dpqRq9q=
H$ialg - i=
$=3s fi # i $ i g
*$= iiEE = q E
$ [ r sE ; ' ] s
F8S 3'd 3 at
:5308Fnq$g
td 8E
+\.Ff55 (Dog 3
st E
5d e&ss
s't
qi =.
Eldru
UE!rO
o
oo)
oo
t\) N)
JO JO
1\) 1\)oo
\q
HMo
$h
sFBtrE$
J?=: I
CN(D
(D
V)
S ]E]$ ---l<l'
EEfu
{
6
Ic)om
d
@bo
td;!-toxlIffi DffiIffiffi
b0
E
dLtr
tHo
L
I9rn9r*
h c.r
o:sh
c))rA(A
(t-{o
!)
GI€
a
Eo.tr
(n
F()>.
(Do!
o(l)
H
AX(D
c)
6lc)E
Ec.)o
(tt
3t*
F;o66(\I CD-o@>
(l,o
c65J?
trEF= ,=4Eg Er
fr{ $gE :Ei t9
E iE lfu=: EE tro-bE ET E3'=tr =e. ilEi
r A']gfig v= rrr ulz == HrcBl
Hf-{
g
tlrHHIF
{E
AzIfEElH
\N
$
$s
2o
I
F
{
(,
Ilr
-FE
ltl
(,
-o
I
l-
(,
ltlFoEg
ulu
I
IL
4E*
#
e
UF:l-{
i$
,iit
;::a{:; ' :::':,.::.: .,..i',r; : : :: .
",,,:t,:,ti:r'l
:.ria-:;.:;::t,,ii.!a:a':t::*ri"i:::*','i;i;
, ,:-i../,,t:;:.':i
,,i..:f*
June 15,2012
Mr. Edmund Mafthews
Northemtier Fire/Ace Fire
1353 Elm St.
Helena" MT 59601
DearEdmund,
This is to confirm your attendance at a Seminar in Las Vegas on
June 8ft, where you received a score af 93% on the test given at the class.
The following Commercial Systems were covered at that progam.
Ansul
R102 -Ansulex, 1.5 gallon & 3 gallon Wet Chemical Systems
Piranha PRX-7 (1.5ga1.)-10 (2.5gat)-13 (3gal) Water Assisted Wet Chemical Systems
Auto Fry Ansul Wet Chemical System Ventless Hood model MTI40, MTI-10, MTI-5
Kidde
Aqua Blue WHDR-250, 500, WHDR450 & 900
APC WHDR-125,260, 400L, 4005
Control Heads- Mechanical KRS-50 & XV
Range Guard
2 Yz querrt,S quart 2l/2 gal. & 6 gal.
Control Heads- Mechanical Head, Mechanical Box, A-Plus & Universal
Pyro Chem
PCL 165, 24O, 350,460, 600
Kitchen Knigbt 11, 160, 300, 460, 600
Control Heads- MCH PCL And Knight ll
i't::,:*':.i:.
ii'j
:.,:
Protex
Model 240A,3500, 5500
Protex Series 11 L1600,3000,4600' 6000
Control Heads- Protex 2000 & Protex I I
Amerex
KP 2.75,3.75,4.75,600
Control Heads- MRM, MRM-2 & PRM
Buckeye
Kitchen Mister BFR-5, 10,15,20
Control Head- SRM
Should there be any other questions please contact me-
Sincerely
.4)oU
Edward O Brien
Director of Training
ii"i;
Receipt Number:@119:r;ie{
I
nity Development
'9, lD. 83440
x (208) 359-3022
,;.
?,:1..i&n
$ 100.00
genpmtneceipts Page 1 of 1