HomeMy WebLinkAboutALL DOCS - 12-00042 - Shilo Automatic Sprinklers Annual Certificationa
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Rexburg -Modison Counly
www.rexburg.org
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022
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35N l.rF
Rexburg, lD 83440
PERMIT#:
$100 Fee Paid: Yes/No Permit Approved: Yes/No
BY:Date:
",1 tr,rtU slstem certtfcation pennit is reqaired to instal/, nodtfi, maintain, or seruice a// new and existingfre
extittiri.rhers. fire suppresion ystens, -fire alarnt syrtetzs, and other /ife salegr ymms within the Ciry of Rexbury"
BUSINESS NAME:
OFFTCEADDRESS, I4 llt*hu il. nf.,^/o yb trun
oFFrcE pHoNE NUMBER, 20{ _AJob _@b
coNTAcT PERSoN: <4o.a Te s cELL pHoNE #: 208-ffio-<4,
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECKALL
THAT APPLY.
-FIRE ALARM SYSTEMS - Alatm Contractors shall have a minimum of NICET Level 1
Certifications or equivalent.
.i. PLE,ASE, PROVIDE, CERTIFICATIONS :
.:.NICET Cerrificadon
'.' l'anel Lertltlcailon
{.Proof of Liabilitv Insurance
{. PLE,ASE PROVIDE CERTItrICATIONS :
.i. NICET C ertification
*Any Additional Certifications
{'Proof of Liabiliw Insurance
-FIRE EXTINGUISHERS
-SMOKE CONTROL SYSTEMS
9,, SPECIAL HAZARD SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
I/ STANDPIPE SYSTEMS
./'FIRE PUMPS
*T"VWW.NW WWTDW W @F ?R.4Z]NIZSV'G LW:LS,yt vs?1{z,z,A7Y'@sy w, LyAwwwY vN.swwAN[cw, wTc. w@w. ]LLv,
DTSZPIIY'SVE5:*|#*
COMPANY NAME:PHONE #:
**PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF
THIS FORMX*
I certif' that I have read this application and declare under penalty of perjury that the information contained
herein is colrect and complete. I agree to comply with all city ordinances, adopted codes, and state laws
relating to the installation, modification, service, and maintenance of new and existing life safety systems. I
hereby authorize representatives of this city to inspect any work for compliance purposes. I am either the
contractor responsible for the work, or I represent the owner as signified above and am acting with the owner's
,/contractor's full knowledge or consent.
COMPANYNAME: ftil" frre?t.k-Ll,-, PHONE #, 4toU *oG
PRINT NAME OF APPLICANT
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BUSINESSNAME: 5h,,lo A',|o,r"nh. ?f , t rn.
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANY NAME: b eLce e*cA^/a+.-"^ pHONE #:4,,L2-bso,>
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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APPLICANT'S SIGNATURE
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FEB-08-a0l a(uE0) I 4: 59
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5HILO (FflX)e0806678905PR I NKLER
o
P 002/00e
,qiorcif CERTIFICATE OF LIABILITY INSURANCE DAIE lMMrOOrYYan')
LO|T l20LL
THIS CERNFICATE IS ISSUED AS A I']'\TTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TI{IS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMENO. EXTEND OR ALTER THE COVERAG€ AFFORDED BY THE POLICIES
BELow. 1{1s cERTtFtcATE oF |NSURANCE DOES NoT co[STtTUTE A CONTRiACT BETVVEEN THE ISSUING TNSURER(S], AUTHORTZED
REPRESET{TATIVE OR PRODUGER, AND THE CERTIFICATE HOLDER-IMpORTANt -lt tho conlllcato holder le an ADDIT|ONAL INSURED, tho pollcy(los) must bc cndorged. lf SUBROGATION lS WAIVEO' subjcct to
lhc Cenng End conditionB of the pollcy, conaln pollclc'e msy rsquir€ an andofsement. A statemont on thls ccrtlllcate doca not confo. rightt to the
cenltlcato holdor In llcu of such endorEomont(61. _
PROOUCGR
Cunnington t A.ssociates, Inc.
P.O. EOX 429
Eagle ID 83516
::g:i"t Brend.s Ellio
nFNS^ .-.. (208) 5?2-5180 | Ii:i *.,. (zosrr?3-s!Bo
F-.TS!"". b=enC.a I cr:nni.n gt,onin s . coli
tilslJRERlSl AFFORll|t\tO C0vE FAoE NAIC T
rrusunrnlNautilus Insurance Group ;9301
INSUREO
Shilo Autosatic SPrinlclers Inc
1224 11th Ave N
Nanilpa ID 83587
rrvsunen e National Union Fire Ins. Co.19445
rxsunrnc:Scotts.lrl-e Ins Co t1297
rrrguneno,Ins. Cg, 9Eate of Pennsyl-vania tt9a29
INSUPFN F ?
INqUR€I F
TENUMBER:9 ILL c'. E:K PI.11FC AITIO REVISIONNUMBER
fhIS IS TO CERTIFY THAT THE POLIC]ES OF INSUR/\NCE LISTED EELOW HAVE BEEN ISSUED TO TI'IE INSUREO NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTMCT OR OTHER DOCUMENT WTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFOROEO BY THE POLICIES OESCRIBEO HEREIN IS SUSJECT TO ALL TH€ TERMS,
EXCTUSIONS AND CONDITIONS OF SUCH FOLICIES, LIMITS STIOWTI MAY HAVE BEEN REDUCED BY PAID CTAIMS.
TytE gF ltrrguRANCE D6r reYNllMnrp lrnxg
A
OENERAL IIABILITY
il a,orur*",* GENERAL LtAourY
I Jct MS.MADEIXIOCqJR
I Dcductllrla E5,OOO
:cP200386?00 tt30t20LL ,13012fl12
E^CI{ OCCURRCNCE s 1,000,00c
IJAMAIiL IO HhNILU : 100,00€
MEDEXP IAnY m OmnI r 5, ooc
PERSONAI A A:V INJTIIIV 3 1,0O0 .000
GENEML AOGREOATE , 2,000,00c
GEML AGGREGATG LIMIT APPLIES PER:PRODT.CTS . COMP'OP AGG s 2,0OO,00C
$
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AUTOTOAILE UASUTV
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IALLOWNED I ISCHhAJTEI)I AUTO!t LJ AUTOS
vl I v INON.O\wiIED3.1 HrREoAt Toti I .:_.1 ^urosttl
! 150t592 .lLl20L/ll/2ar2
iU UINULE LIMI I s 1.000. OOC
EODtLv INJURY (Pcrps:m)$
BODILY INJURY (Po. ocddonl)t
rx9PtH rY rlaMA$E 3
3
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UMBRELLA UAB
€ICEES UAB
x I occun--l.,o,ror^^.
3.SOO77338 tl30l20LL tl30l20L2
IiACH OCCI'RRENCE r 3,000,00(
x AGGREOATE c 3.0o0.ooc
nsn lXlo"t"*r,^"s 1o,oo 3
D WORXERS COMPENSANgX
at{oEMPLOYERS'UAEilltrY YtNANY PROPRIETOR/PARTNEF'EXF,CUTIVE T:;_I N'A
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|c 4521182 (ros)lrl2orr )lL/2oL2
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FR
E.L. Facl.l ACCIOEI,II s 1. OOO _ OOC
OFNCEf'/MEMEERO(CLUDES? II I(ilrnojrlory In NHI
ll yc do<nbc unddI\GQ.DIDTIAN nE MnAnN!: hfu
E.L DISEASE. EA EMPLOYE 1 1, OOO . OoC
E.L. OISEASE - POLTCY LIMIT r 1.000 . 00(
A Profeaaional Lhbt llty
9/3olo9 Rotro
:cP200396?00 tl30l20LL ,l30l"ol'2 potdolrn 1rO00rO0(
o€duciDrotsdrin 5.00(
OESCnpnOilOFOF€Ra'IONSTLOCAnOilSTVEhICLES i nrcnACoRDl0'l,AddlllmltRma't!schrdulc,lflllor!E9.colo'9oulreall
PEgof of Cowe=age
Proof of Coverage
SHOULD^IiIY OFTHE ABOVE OSSCRJBED POLICIES 9E CATICEILED BEFORE
THE FIPIMTION DATE NIEREOF, '{OTICE WILI BE DEUVERED IN
AOCOROANCE WTH TT{E POLICY PROVISIONS.
AU''IOFI'EP iEFRC6EI{?ANVE
Baondr Eur3/BRELr,r €t^ --"-"LAX€AA. r-
@ 1988-20't 0 Atl roserved,ACORD 25 (2010105)
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rlghts
-
,evelopment
D. 83440
108) 359-3022
$100.00
$100.00
$100.00
tlTY [F tl[:iEUH[
FA1TI FYI 5HILff AuTCIi'lfiT1[ 9FTIII{}iLTR5
trATE: 0tl0,ii1t l'1[ l0i[]i[]lTR
Tlt{E: li:4S:lrl ntCtIfT i'l[: -144108
F:EF t{t: 0810*-fi
I BF FIRE Ptfti{fT rjilt'ER :
[Hr[]i {ll',l0ljilT
FAYI.TEIIT
IHfiIiEE
PERI'i1T *L: 0ff[4i
THA'rlli YUU filltr HA"JE A l{ltE IAT
itrl,[0
10il . il[
lCIf,00
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$ 100.00
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genpmtrreceipts Page 1 of 1
Glty of Rexburg
Oepartment of Communityr Development Receipt Number: 1,?!!1.Xt ,.|
35 North 1st East / Rexburg, lD. 83440
Phone (208) 359-3020 / Fax (208) 359-3022
12 00042 Base Fire Fee
CHECK 085088 $ 100.00
Total:$100.00
FEB o 3 2012
CffY OF REXBURG
genpmtreceipts Page 1 of 1