HomeMy WebLinkAboutALL DOCS - 12-00080 - Peak Alarm Company Annual Certificationoo
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35N ldE
Rexbwg,D 83440
Rexburg -Modison Counfy
Emergency Services
Phone:208.372.2326
Fox:208-359.3022www.rexburg.orE
CITY OF
REXBURGcs' -
Am t ri c * s F a m ily Com mu n ity
PERMIT#. 1,7' M@
$100 Fee Paid: Yes/No Permit Apptoved: Yes/No
BY: Date:-
"A safery gstun certtfcation pemit is reqwired to install, nodifi, maintain, or seruice all new and existingfre
extinguishers,fre suppression slstems,fre alarm rystems, and other life safefl gstens within tbe Ci4t of Rexburg"
BUSINESS NAME:
OFFICE ADDRESS:
OFFICE PHONE NUMBER:908'5a4- 4>sa
coNTACT PERSoN: Ll,,-*JoLn CELL PHONE #:
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL
THAT APPLY.
/ ftnf ALARM SYSTEMS - Alaffi Conftacrots shall have a minimum of NICET Level 1
C.rtifi.rtioos ot equivalent.
{.PLEASE PROVIDE, CE,RTIF'ICATIONS:
.INICET Certitication
{'Panel Certification
{.Proof of Liability Insutance
AUTOMATIC SPRINKLER SYSTEMS *Fire Sprinkler Contractors shall have a
minimum of NICET Level III Certifications or equivalent.
{.PLEASE PROVIDE, CERTIFICATIONS:
€.NlCET Certification
{'Any Additional Certifi cations
t Proof of Liability Insurance
FIRE EXTINGUISHERS -STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS FIRE PUMPS
-SPECIAL HAZARD SYSTEMS
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
*]'*PLE/ESE PROWDE DOCAMENTATION OF TRAINING LEWLE
INSTALLATION CENTIFICATIONS, LIABILITY INS URAATCE, ETC, FOR .lLL
BUSINESS NAME:
PLEASE LIST ALL
REPRESENT:
COMPAI{YNAME:
COMPANYNAME;
COMPANYNAME:
COMPANIES YOUR BUSINESS IS AUTHORIZED TO
PHONE #:
PHONE #:
PHONE #:{"I.PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF
THIS FORM**
I certi$ that I have read this application and declare under penalty of periury that the information contained
herein is correct 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 exis trg life safety systems. I
hereby authorize represefltatives of this city to inspect any work for compliance purposes. I am either the
contlactor responsible for the work, or I represent the owner as signified above and am acting with the ownet's
/contractorts full knowledge or consent.
V';-1*hh^: -E,erTJot o ftta-qg*
PRINT NAME OF APPLICANT
Jlet lzot>
APPLI
DATE
PERMIT VALID I.INTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
{ol.{.{ola*:lslel*:N$*{.{olel.:fr{$l$l$l.ffirlolsl.:l.J$Srl.tl.ffi*s*{.rF .:lslc|sl(:t
DTSIPLINES***
ACORq-CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DIYYYYY)
03/28/20L2THlscERTlF|cATEls|ssUEDAsAMATTERoFlNFoRMATtot.torlYnrocot.tFERsNo[RtG}|TsUPoNTHEm
CERTIFICATE 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 ISSUING INSURER(S), AUTHORTZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMFL,l(|ANl:|IInecetT[|caleno|derisanADD|T|oNAL|NsURED'thepo|icy(ies)mustbeendoFeo
the terms and conditions of the policy, ceilain policies may require an endorsement. A statement on this ceftificate does not confer rights to theceftaficate holder in lieu of such endorsement(s).
PRODUCER
Berrian fnsurance Group, fnc.
10375 Park Meadows Drive
Suite 220
Littleton, C0 80124
ilXilEi'' Brian Zilverberg
iil8"ru=o. e*r, 303. 327. 5gg1 | li6. no,, 303 . 795 . 5E33
E.MAILADDRESS:
tNsuRER{Sl AFFORO|Nc COVERAGE NAtc#
tNsuRERA: Philadelphia Ins. fndennity Co.1805EtNsuRED PeaK Atarm Co. Inc.
1534 S Gladiola
Salt Lake City, UT E4104
TNSURERB: valley Forge Insurance Co.2050E
rNsuRERc: Anerican Casualty Co of Reading,20427
INSURER D :
INSURER E :
INSURER F
COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:|n|J|D|uUEK||rY|nA||l,|ts'tJuL|U|EsoF|NsURANcEL|sTEDBELoWHAVEBEEN|SSUEDToTHE|NsUREDN
INDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWTH 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.
WPE OF INSURANCE INSF WN POLICY NUMBER ruuur Ett(MM/DD/YYM tsULIUY Uts(MM'DDfYYM LIMITS
A
GE
T
X
\IERAL LI,ABIUTY
COMMERCIAL GENERAL LIABILITY
cLAIMs-MADElXlorcun
& Omissions
PHPKE4657]04101t201204101t20't3EACH OCCURRENCE $ 1.000.00(
UAMASE IUKENIEU
PREMISES (Ea occun€nce)s 100.00(
MED EXP (Any ons person)s 5.00(
PERSONAL & ADV INJURY $ 1.000.00(
GENERAL AGGREGATE s 2,000.00(
GEN'L AGGREGATE LIMIT APPLIES PER:
X'l po.rc" l-l l5g l--l .o"
PRODUCTS - COMP/OP AGG s 2.000.00(
!
c
AU'IOMOBILE LIABILITY
lo*^*oI ALLOWIED T--I SCHEDULEDIAUTOS I IAUTOS
HTREDAUTos lTllS+S*toTI
402E78801o4t01t201204t01t2013WUIOII\EU DII\gltr LIMI I(Ea asident)s 1.000.001xBODILY INJURY (Per peEon)D
BODILY INJURY (Per accident)s
I'rNVTEI I T UAMASE(Psr a@idert)
E
A
x UMBRELLA LIAE
EXCESS LIAB
X I occun PHUB377E7:04t01t201204t01t2013EACH OCCURRENCE s 5.000.00(
CLAIMS.MADE AGGREGATE $ 5.000.00(oeo I X lnerEr'rrror.ro 10,00(o
WVKAEG WMTENU I IVN
AND EMPLOYERS'UABIUTY
N/A
I v\(;srAtu- | toTH.ITORYLIMITSI IFR
AIIY PRoPRIEToR/PARTNER/ExEcUTIV#OFFICER/MEMBEREXCLUDED? I I(Mandatory in NHI
lf yeg, dessibc undat
DESCRIPTION OF OPEMTIONS belo,i,
E.L, EACHACCIDENT !
E,L. DISEASE - EA EMPLOYEI
E.L. DISEASE. POLICY LIMIT $
B
-onmercial Property 40287EEO?!04t0'U201204/,0112013Refer. to policy for limits
DEscRlPTloN oF oPERAnoNs / LOCAIIONS / VEHIOLES (Attach AcoRD 101, nooi0ont nenrar*s Sctreoure, r more ipace rs requlrtOl
tlarm and Security Conpany
ividence of Insurance
CERTIFICATE HOLDER CANCELLATION
City of Rexburg
Attn: Janell Hansen
19 E Mafn St.
SHOULD ANY OF THEABOVE DESCR'gED POLICIES BE CANCELLED BEFORE
THE EXPIRANON DATE THEREOF, NOTICE WLL BE DELIVERED IN
ACCORDANCE WTH THE POUCY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Joel Berrian
1988-2010 ACORD
ACORD 25 (2010/05)The ACORD name and logo.are registered marks of ACORD
All rights reserved.
ACORq-CE ATE OF LlABlLlw INStfiANCE DATE{TX,ID'YYYYI
02/21-120t2
THIS CERNFrcATE IS ISSUEDASA NATTEROF INFORTATION OilLYAND CONFERS NO RIGHTS UPOI{ THECERTIFICATE HOLDER THIS
CERNFrcATE DOES NOT AFFIRtrANVELY OR ilEGATIVELY ASE}ID, EXTEIID OR ALTER THE GOVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERnFTATE OF TiTSURAilCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE tSSUiltc THSURER(SI, AUTHORTZED
REPRESENTATTVE OR PRODUCER, AND THE CERTIFICATE HOLDER
ItP(,t( | AII | : $ ure aetBficale no|dor i$ an Atxrfngt|AL II{SURED, lno polacy{a€l must De enrlolsed. tf SUBROGATIOT{ lS UIAIVED, subject to
the tenf|s and conditaons of the policy, certain policies rnay require an endorsement A slatenrent on thb certificate ds not confer rights to the
certificate holder in lieu of such endorsemen{s}.
PRODUCER
Berrian Insurance Gr"oup, fnc.
1O375 Park lileadous Drive
Suite 22O
Littleton, CO EOIZ4
Xffii?"' Brian Zilverberg
frH*"l =*.. 303. 795. 5E3l I r# "^" 303. 795. 5E33
E{AILAIX)RESS:
IttsuRER{s} AFFORDFTG OOTTERAGE NAIC'
n{slrRERA: Philadelphia Ins. Indermity Co.18058
rNsuRED reaK Atam Lo. lnc.
1534 S Gladiola
salt Lake city, uT E41O4
tilsrrRERB: Val-ley Forge Insurance Co.2050E
IilSURER C :
INSI.'RER D:
INSURER E:
INSI'RER F :
COVERAGES CERTIFICATENUIIBER:1l-12 Cer,t cates REVlSlOlrl NllllBFR:
I nlD 15 lu t,EK I lrY I FlAl I HE l'ULlUlES (Jt- IN5UKANUE Lltil EU ttELUW FIAVE ttEEN lliliutu I U I Ht INIiURLU NAMTU ABOVE FOR THE P(]LICY PERIQDINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT TO VWITCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLTCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOVI'}I MAY HAVE BEEN REDUCED BY PAID CLAIMS.
il$
LTR TYPE OF INSURA'{CE NSn nrD PlOI-rcYilUIIBER rugtrFIII'DDA|YYYI uttTs
A
GEIiIERAL LIABIUW
x I co^rrrencm cENERAL uABrurY----l---r t-
I ICLATM9MADE I X loccuRX lErrors & 0nrissions
PHPK6990204,lail201104tailmI2 EACH OCCURRENCE i I,OOO,O(X
PREMISES{Eam@)$ loo.oo(
MEDE)(P(Arympers)o 5.fiX
PERSONAL & ADV INJURY s 1.fi10.0fl
I GENERAL AGGREGATE r 2,fi)O,0&
GEN'L AGGREGATE UMIT APPUES PER:
xl "ot'"" n fF"g l*l toc
PROU'CTS - COMP'OP AGG s 2,{X)O,O0(
B
AUTOIOBS-E LIABIUTY
Tl *"ouro__-1 ALL OW\IED f___l SCHEDULEDIAUTOS I IAUTOSxl **.oorr* [-il Xm*to_ln
40287E601 04,roil201l o1to1t2012 r ffik ent)r, 1,(X)0,0(X
BODILY ll{JURY (Ps pffin)s
BODILY llt URY {Ptrailent)s
TKUTtsKIY ffits
{Per ffiidtrt)$
$
A
x UTBREI-A LIAB
EXCESS LIAB
X I occua_l
"*,rr*ooo,
PHUB33975(|'4nItzafi utoilm12EACH OCCURRENCE c S,(XIO,O0(
AGGREGATE r S.fi)O.OO(
oeo I X I ce-rerurront IO'OU $
wm6vuaru*tts
ANDEflPLOYERSLUTBTUTY YrilANY PROFRIETORiFARTNER/EXECUTIVE-r
OFFICER/I'EMBER EXCLUDED? I I
(tand*ory in NH) l'-J
lf y6, dKibe under
DESCRIPTION OF OPERATIONS bebrv
N'A
I wv orAre I t9rr
ITORYUMITSI IER
E,L EACH ACCIDENT $
E.L DISEASE. EA EMPLOYEI $
E-L. DISEASE. POUCY LIIIIT I
B
:omErcial Pr.operty 40za7aEazlo1to1t201104to1t2012 Refer. to policy for Iimits
DESCRIPTIONOFOPERATIOIISTLOCATIOIiIS/\rEH|CISS {AttacftACORlrl0l,AddiltdrlRsailtsSctEdule,ifmoespaeisrcqrired)
ividence of Insurance.
CERTIFICATE HOLDER CANCELLANON
City of Rexburg Building Departrrent
35NlstE
Re>qburg, ID E334O
SHOI'LD ANY OF THE ABOVE DESCfiIBED POLEIES BE CANCELLED BEFORE
THE EXPIRAnOil DATE THEREOF, lrlOTlCE WILL BE DELMRED lN
ACCORDAI{CE wlTH IHE FdICY PRCMSOI{S.
AUTHORIZED REPRESE}ITATNE
foel Berian
@
The ACORD name and logo are registered marks of ACORD
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-Receipt Number:
. 83440
)8) 359-3022
$100.00
Total:
$ 100.00
FEB 2 4 2017'
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