HomeMy WebLinkAboutALL DOCS - 12-00065 - Omni Security Systems Annual Certificationvlt
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35N l"E
Rexburg, lD 83440
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
-SPECIAL FIAZARD SYSTEMS
-FIRE PUMP
www.rexourg.org
"A tortU gystem certfrcation permit is required to install, nodtfi, maintain, or senice all new and existingfire
extinguisbers,fre suppression t1stems,firc alarm gtstems, and otber lfe safery ysnns within tbe Ci4t of Rexburg"
BUSINESS NAME: T1
OFFICE ADDRESS:
OFFICE PHONE NUMBER:
CONTACT PERSON, "/"'lE
Rexburg -Modison Cou nly
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECK ALL
THAT APPLY.
4
A-FIRE ALARM SYSTEMS - Alatm Contractors shall have a. minimum of NICET Level 1
Certifications or equivalent.
* PLEASE, PROVIDE CERTIFICATIONS:
{.NICET Certification
{.Panel Certification
.!.Proof of Liability Insurance
T NICET Level II required for design work
AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinklet Contractors shall havea
minimum of NICET Level I Cetifications or equivalent.
{.PLEASE PROVIDE CERTIFICATIONS:
.:.NICET Cetification
* Any Additional C ertifications
{.Proof of Liability Insurance
t NICET Level II required for design work
-FIRE EXTINGUISHERS
*Proof of Certification & Training
-AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
{.Proof of ftaining for commercial cooking heads
REXBURG
Am e ri cai Familv Co flrnluni ty
cELLPHoNE *,fu€3fu2226
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{€{1*PIEASE PROWDE DOCUMENTATION OF TRAINING LEUELS,rNsrArrATroN cERTrFrcATror\rs, LraBrLrTr rNsuR[NCE, ETC. FoR ALL
DISIPLINEStct<*
I cetti$ that I have tead this application and declate undet penalty of petiury that the information containedhetein is cortect and complete. I agree to comply with all city otdinan".", udopt a codes, and state lawstelating to the installation, modification, service, and maintenance of new aniexisting liie safety systems. Iheteby authorize teptesentatives of this city to inspect arry wotk fot compliance purpo-ses. I am eithet thecontractot tesponsible {o1the wotlq ot I teptesent the ownet as signified above and am acting with the owneds
/contractot's full knowledge ot consent.
PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.************tls******:F*******************************************rt *{.rt:t *:ft*{.*t(*****
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ACORQ"
COVERAGES CERTIFICATE NUMBER: 12-13 CMB REVISION NUMBER:
CERTI ATE OF LtABtLtTY tNSrfANcE DATE (MM'DDTYYYY}
0L/19/20t2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW THIS CERTIFICATE OF INSUMNCE DOES NOT CONSTITUTE A CONTMCT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certincate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. lf SUBROGATION lS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
Archibald Insurance Center
500 S Woodruff
PO Box 2498
Idaho Fal'ls, ID 83401
ixill?"' Christy Bartholomei
ll3.*fi..,o, 208. 524. 5858 | lih^,,208. 522.8049
FiH!"", chri sty-barthol omei@1 eavitt. com
:IPPX"9:s," ". 0003470s
INSURER(S} AFFORDING COVERAGE NAIC #
INSURED
Omni Security Systems,Inc.
DBA: Omni Properties, LLC
PO Box 309
Rigby, ID 83442
TN5SRERA: Philadelphia Ins Group R18667
TN5SRERB: Idaho State Insurance Fund 36L29
INSURER C :
INSURER D :
INSURER E:
INSURER F:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO WHICH TH|S
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUMNCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHO!\N MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POUCY NUMBER tsULIUY EIts,MMrnnffit LIMITlI
A
GE
I
NERAL LLABILITY
I co""e^c'ot ceNERAL LIABrLrrY
fl.*,".-"oo. lTloccu*T-
PHPK815I2'01t0'U201201t01t2013EACH OCCURRENCE $ 1.000.00(
UAMAUtr I9KEI\IEU
PRFMISFS /Fa md man.a\o 100.00(
MED EXP (Any one person)s 5.00(
PERSONAL & ADV INJURY $ 1.000.001
UEI\EKAL AUUKEUA I tr $ 2.000.001
\.1 AGGREGATE LIMIT APPLIES PERJ
I --- pR6-
IPOLICYi lrih-r I ILOC
PRODUCTS . COMP/OP AGG $ 2.000.001
o
AUTOMOBILE UABILITY
| ^r" ^rro
I ALL o\ NED Auros
I ScHEDULED AUTOS
| ,,*to ^rto.IINONOV1AEDAUTOS
COMBINED SINGLE LIMIT
(Ea accidenl)
BODILY INJURY (Por person)
BODILY INJURY (Per accident)
PROPERry DAMAGE
(Per aeidsnt)
J
A
UMBRELLA LIAB
EXCESS LIAB
x OCCUR
CLAIMS-MADE
PHUB37074:01t01t201201t01t2013EACH OCCURRENCE s 2.000.00(x $ 2.000.00(
DEDUCTIBLE
RErENrtoN $ 10,00(X D
B
ANDEMPLOYERS'LlABlLlry y/ N
ANY PROPRIETORYPARTNER/EXECUTIVEf--I
OFFICER/MEI\4BER EXCLUDED? I I(Mandatory In NHI
lf v6s. desdbe undernFsaRrprroN oF nPFRATToNS herow
N/A
57598104t01t201104t01t2012 I vvvor^ru- | tvrn.
E.L. EACH ACCIDENT $ 1.000.00(
E.L. DISEASE. EA EMPLOYEIo 1.000.00(
E.L. DISEASE - POLICY LIMIT $ 1.000.00(
DESCRIPTIONOFOPERATIONS/LOCATIONS/VEHICLES {AfiachACORDl0l,AddltionalRemarksSchedule,lfmor€spacoisrequired}
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE e.lqqy'Boilhd"n"i.
Christy Bartholomei
@ 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD 25 (2009/09)
."._ lllf-g
(Rev. October 2007)
Pf:;:IH:1"'i"iiltr:'""
Request for Taxpayer
Ndentiflcation Nurnber and Cedificatios?
Give form to the
requester, Do not
send to the lRS.
o(')
Co
Name (as shown on your income tax return)
Omni Security Systems, Inc.
Business name, if differenl from aoove
>.=
vY^
o
o
a
Check appropriate box: I Individual/Sole proprietor E corporation ! partnership
LJ Limited liability company. Enter the tax classificaiion (D=disregarded entity, C=corporation, p=partnership) )
f Otherlseeinstruciions) >
1 Exempt
" payee
Address (number, street, and apt. or suile no.)
Po Box 309 / 3905 E.200 N.
Requester's name and address (optional)
City, state, and ZIP code
Rigby ldaho 83442
List account number(s) here (optional)
T ldentification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoidbackup withholding. For individuals, this is your social security number (SSN). Hbwever, for a residentalien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it isyour employer identification number (ElN). lf you do not have a number, see How to get a I/N on page 3
Note, lf the account is in more than one name, see the chart on page 4 for guidelines on whosenumber to enter.
!eJ/'\
Social security numbet
Certification
Under penalties of perjury, I cedify that:
1 . The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not sub.iect to backup.withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the IntemalRevenue Service (lRS) that I am subject to backup withholding as a result oi a failure to rJport all interest or dividends, or 1d; tfre lnS nasnotified me that I am no longer subiect to backup withholding, and
3. I arr a U.S. citizen or other U.S. person (defined below).
Certification instructions' You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backupwithholding because you have failed to feport atl interest and dividends on your tax retuin. For real estite transactions, item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured properti, cancellation of debt, contributions to an individual retirementarrangement (lRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, Out you mustprovide your correct TlN. SeeAe instructions on page 4.
II t-,Sign
Here Date )
General Instructions
Section references are to the Internal Revenue Code unlessotherwise noied.
Purpose of Form
A person who is required to file an information return with the
IRS must obtain your correct taxpayer identification number fflN)to repod, for example, income paid to you, real estate
transactions, mortgage interest you paid, acquisition orabandonment of secured property, cancellation of debt, orcontributions you made to an lRA.
t/le FoTn W-9 only if you are a U.S. person (including aresident alien), to provide your correct TIN to the person
requesting it (the requester) and, when applicable, to:
1,. Certify that the TIN you are giving is correct (or you arewaiting for a number to be issued),
2. Cerlity that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S,
glgmpt payee. lf applicable, you are also cer.tifyinil that as aU.S. person, your allocable share of any partnersh'ip income froma U.S. trade or business is not subjeci io the withholding tax onforeign padners' share of effectively connected income.
Note. lf a requester gives you a form oiher than Form W_g torequest your TlN, you must use the requester,s form if it issubstantially similar to this Form W-9.
Definition of.a_U.S. person. For federal tax purposes, you areconsidered a U.S. person if you are:
o An individual who is a U.S. citizen or U.S. resident aiien,
. A partnership, corporation, company, or association created ororganized in the United States or under the laws of the UnitedStates,
o An estate (other than. a foreign estate), or
. A domestic trust (as defined in Regulations section301.7701-7).
Special rules for partnerships. Partnerships that conoucr atrade or business in the United States are generally required topay a withholding tax on any foreign partners' shaie of incomefrom such business. Fudher, in cedain cases where a Form W_ghas not been received, a partnership is required to presume thai
g.partner is_a foreign pgrs_on, and pay the withholding tax.Therefore, if you are a U.S. person tfiat is a partner in apartnership conducting a trade or business iir the United States,provide Form W-9 to the partnership to establish Vour U.S.status and avoid withholding on your share of pa*nership
income.
The person who gives Form W-9 to the partnershio forpurposes of.establishing its U.S. status and avoiding withholdingon its allocable share of net income from the parlne-rship
conducting a trade or business in the United States is in thefollowing cases:
o The U.S. owner of a disregarded entity and not the entitv,
Employer identitication number
73 i tesaaoa
Cat. No. 10231X Form W-9 (Rev. 1O-2oO7l
T.ype
ELE JOURNEYMAN
Mark Pettichord
ELE CONTRACTOR
Omni Security
Systems
LidCert
ELE-J-12167
ELE-C-15009
Issued Expires
6t4t08 7/31t14
6/16/08 2/28/12
Receipt Number:unity Development
rlTI [F FETFURG rrg, lD. 83440
rx (208) 359-3022
PAIIr SY: 0HllI SECURIT\
lAlE: 01/31/11
TII{[:13:03;40
SYSTEI'IS INI
1?-'.?Tlil-Il,0,*
ttF il0r 16?4'ci
40 lF Fiftt FEtli{IT uNirER r
tHECti At',l0ullT
FAlI,IE}.IT
IHANSE
FEftl'lIT *1? 0fi065
TI.IANIi YOU ANTI HALIE A NIIE IIAT
1[0.oii
10il.fi0
100. CI0
|l.00
orqlQ{lFee
Attount
$100.00
Total:
$100.00
$100.00
Total:$100.00
PAI
FEB 2 l 2017
CITY OF REXBURG
$ 100.00
genpmtneceipts Page 1 of 1