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yone/lh{*rexburg.org
www.rexburg.org
Emergency Services
Phone; 208.3SgJAZAfiZ6
Fax:2A8359.3024
i9 fOst Moin Sl
Rexburg, lD 83440
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PERMIT#:
$100f-ee Pdd: Yes/No Permit Approved: yes/Nn
or'rcn ADDRs$s, - -6t o- *rc] ! ya-_ _ qlc1]u.*qr*_.gA f7->-
oFFICEPHoNENUMBER, _^d-t K - }9 L_J6( "
coNrACr PERSoN: {o @ 14 L, '*-CELL FHONE #:,:11 7 f
PLEASE ID$NTIFY SYSTHMS TO BE COVERED SY THIS PERMIT. CHECK ALLTHAT APPLY.
!-;IIR.E ALARM SYSTEMS - r\larm (lontractors s!'rall have a minirnurn of NICI;T l.evel 1(.crtrllcnf l()ns or cquir-alent.
* PLEIi\S[i I,ROV I Dt i C [,]KI't ]r IC i\"t.tONS:
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-Lt' p'urolvlATlc SPRIIIKLER SYSTEMS * Iiirc sprinklcr (.onrrncr.,r* *h"lihar c r Ltr;t.t i. icafin1
minimurrr of N ICli'r' I-cvcl #tlertificrrtions or e.luivale't.
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"l' N t{ : }':' t' Cerrifi cation
{'.\nr' :\tltlitional Ceruficarions
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- slEcrLl_ HAZARD SYSTEMS
-_*:AUTOMATIC FIRE EXTINCUISHING SYSTEMS FOR COMMERCIALcooKING .-Ln,, ,., . {v, n r' j4 Iltct,,t.rr Ui{ 1(',' (i U,t,pln.f'rttt' i t151,(,'ai Afa.d,,i)
COMPANY NAMF:
COMPAT{Y NAME:
COMPAFIY NAME:
***PLEASE PROVTDfr frOCAMENTATION OF TNANNING LEYELS,
INSTALI*A,TION CERTIFICATIONS, LIABILITY INSURANCE, ETC. FOR ett
MSIpLJNES***
BUSINESS NAMS:(rorri(J o fuw ]r<*
PLEASE LIST ALL COMI'ANIES YO1JR BUSINESS IS AUTHORIZED TOREPRESENT:
PHSNE #: )o( '77 ) -7 61 '
PHONE #:
PHONE #:
,lI I tt-l t)-
DATE I
PSRMI? VALID UNTIL DECEMBER 3T OF THE CALENDAR YEAR APPLIED FOR.{"1'++++:l"l'{*{r:l"l'*+'l*'l"t't'l'+'l'+'l'++tF'1.'{.*'t**'t*'1.**+**tk**rl.*r}*********rl.*****{.***{dt it ***!r*****r}*
**PLEASE LIST ADI}ITIONAL COMPANY AUTHORIZATIONS ON THE BACK OFTHIS FORM**
PRINT NAME OF APPLICANT PLICANT'S SIGNATURE
I cettify that I havc read this application and declare undet penalty of perjury thrt the infotrnntion containedhctein is corect und complete. I agtce to comply with all city otdinancer, ariopted codes, and state lawurelating tr: the installation, n:odificttion, servico, nnd mnintrnrrnce of ncw andexisting tiie safety systcms. Ihereby 4uthorize tepresentatives of this city tn inspect any work for complian". prrrpo,r€*. I am eitlrer thec.oHttdctor respon*ible fnr the wotk, ot I tepreecnt the orvncr as signified ab "yp i"a'y'/"cting with the ownet's,/conttactorts frrll knowledgc or conscnt.' t' t^np_rofu_tbt _
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THIS CERTIFICATE IS IS D CONFERS NO RIGHTS T
cERnFrcArE DoEs Nor AFFIRMATIvELY oR necieiiiEif lmeno' exriib-'dr{rlrei rHE co{ERAGE AFFoRDED BY rHE PouclEs
BELow. rHrs cER FrcArE oF_rNs.uRANgl_"_.j#gi}:x:lt*iii-ciir,rimci BET*EEN rHE rssurNc rNsuRER(s)' AUTH.RTZED
"*EFili=niiit'Gdii'iopucen,anornrcennncre
fficate holder is an ADDtTtoNAL tNoulrEu
il; ifi; and conditions of rho poticy, certatn pollcies may requlrc
ED' sublect tothe pollcy(les) must De e!
an endorseme* e "t"t"r"-ni
on 0ti" cerilffcato does not confer rlghts to the
PROOUCER
l&rtua1 Insurance Assoc', Inc'
1575 BaldY Ave
INSUREO
ril" se*ices of xD Inc, Westertr Fire Equip'
Advantage Fire & Safety, Roaky Mtn Fire
Protection, Fire Protection of, ID LLC
610 f'tallard Avenue
Chr:bbuek ID 83202
EiSlllJi#51ifi'.tr-"lib"di'5Fi",jihr?;-'Jemi'fiiii.'-iffi *;*
BOVE FOR THE POLICY PERIOD
rNDrcArED. NorwrHsrANoilld erii nEoutneuEHt rEn-r'a-b-{conDlr-loN -o! 4HVi-oir-rnnci oC qr-lqngocumEnr wrx REsPEcr ro wtllcH rHls
cERTFTcATE MAy BE rs!u-Fp- 9!IlY.lg$l1l:TT5i$"[5ff,i;*1t#it'Eligti"?tJtr.n^iil",lntlle*iiH rs suerecr ro au rHE rERMe
MERCIAL GENERAL LIABILMY
CLA|MS-MAOE I x loccuR
GENL AGGREGATE LIM(T APPLIES PER:
AUTOMOBILE UABIUTY
ANYAUTO
ALL OWNEO AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNEDAUTOS
BODILY INJURY (Per P3fson)
ANDEMPLOYERS'L|AAIuTY YrNANY PROPRIETORiPARTNER/EXECUTI\G
omcennaeMaEn EXCUJDED?(tlandrrory In NHI
Rtnrfts SchgduL' lf mor"grc' i' r'qulEdl
A'ry e All contlacts aa perfo::oed bt the j.Dsured
SHOULD ANY OF THE ABOVE OESCRIBED POLICTES BE CANCELLED BEFORE
iiii--eiiiri,irrbH oere rn-eneor, NorlcE wtLL sE DEWERED lN
lCioiolnce wrH THE PoucY PRovlsloNs'
a^uandasGrarburg' org
Citl' of Rotburg
35 North lst East
Re:rburg:, ID 83110
Tha ACORD name and looo are
-i9s&2009 AcoRD coRPoRA
reqistered marks of ACORD
All rights res€rYed.
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.,Orlglnal Fee
Amount
Fee
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$0.00
Amount ' '
, Pald.
$r00.00Fee DescrlPtlon
Base Fire Fee $r00.00
Total:$100.00
Anount Pald Permit#
ReceiPt Date
P r"ri"u "
P aYme nt H i story
$100.00
Ecelpt #
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Ethod
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Number
JAN 2 6 ZO\?.
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