HomeMy WebLinkAboutALL DOCS - 14-00014 - Western Automatic Sprinklers Annual Certificationa
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35N l"E
Rexburg, lD 8U40
Rexburg -Mqdison CounfY
Emergency Services
Phone; 208.372.2326
Fox:208.359.3022
c |r'Y o lr
REXBURG
America's Familv Corn nunitv
*A toftU lysten certfication perrzit is required to install, nodtfi, maintain, or service all new and existingfre
extlngu;therc,fre suppression sqstens,fire alarrn gtste3s, and other ffi:afe\t Wtys tllthtn the Ci4t ofRexburg"
. \ " ^- , | ,-
BUSTNESS NAME: \ l.tiil f n l\i-\ur.ritrc $,,n(lt6arcer:
www.rexourg.org
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
-SPECIAL HAZARD SYSTEMS
FIRE PUMP
OFFICE AI}DRESS:0q Irt
OFFICE PHONE NUMBER:
coNrAcr pERSoN, P\ rrt< H c.gon cELL pHoNE #, gD\-'[ (8zoi I
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECKALL
THAT APPLY.
_FIRE ALARM SYSTEMS - Alarm Contractots shall hle t minimum of NICET Level 1
Cetifications or equivalent.
N. PLEASE PROVIDE CERTIFICATIONS:
.:. N I CET C ertification
€'Panel Certification
*Ptoof of Liability Insurance
TNICET Level II tequited fot design work
AUTOMATIC SPRINKLER SYSTEMS * Fire Spdnkler Conftactors shall have a
minimum of NICET Level I Cetifications or equivalent'
{.PLEASE PROVIDE CERTIFICATIONS:
.:. NICET Certification
{' Any Additional Certifi cations
*Proof of Liability Insurance
* NICET Level II tequired for design work
-FIRE EXTINGUISHERS
*Proof of Certification & Training
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
*Proof of training fot commercial cooking heads
-l -
***PIEASE PROUIDE DOCUMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITY INSI]R'ANCE, ETC. FOR ALL
DISIPLINES**rc
I certi$ that I have read this application and declare undet penalty of pefury that the infotmation contained
hetein is cofrect and complete. I .gr.. to comply with all city otdinances, adopted codes, and state laws
telating to the installation, modification, service, and maintenance of new and existing life safety systems. I
heteby authodze tepresentatives of this city to inspect any wotk fot compliance putPoses. I am eithet the
conttactot responsible fot the work, ot I teptesent the ownet as signified above and am acting with the ownet's
APPLI NATURE
\z\lo\ tl
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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/conttactotts full knowledge or consent.
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COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
ACORD,"CERTIFI E OF LIABILITY INSU E DATE (MM'DD/YYYY}
1112012013
ffiUEDAsAMATTERortr.rronmnrroHotllyaHocoHrensNoR|GHTsUPoNTHEcERT|F|cATEHoLDER.TH|s
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING !NSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
ffierisanADD|T|oNAL|NSURED'thepolicy(ies)mustbeendorsed.|fsuBRoGAT!oN!SwAlvEu'suDJedto
the terms and condllons 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
Leavitt Group Ins Advisors
465 South 400 East #300
Salt Lake City, UT 84111
801 308-1500
$PilIlct Mindy Sharp
ll8.nnt . .,u, 801 308-1500 | [i6, nol, 801 398-1427
. mindv.sharp@leavitt.com
TNSURER(SI AFFORDING COVERAGE NAIC #
rNsuRER A : Steadfast Insurance Company 26387
INSURED
Western Automatic Sprinkler Corporation
2510 S West Temple
Salt Lake Gity, UT 84115
tNsuRER B: Workers Compensation Fund 10033
rNsuRER c , First National Insurance Go of 24724
INSURER D :
INSURER E:
INSURER F :
ffiTHEPoL|c|ESoptt{sunnncet-tsreDBELoWHAVEeEeH'tssueoToTHE|NSUREDNAl.,EDABoVEFoRTHEPoLlcYPER|oD
INDICATED. NOTWTHSTANDING ANY REQUIREMENT ENUI ON CONDITION OF ANY CONTMCT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE 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.
TYPE OF INSURANCE POLICY NUMBER POLICY EFFIMM'DD/YYYYI LIMITS
A GENERAL LIABILITY
Xl couuenctn- GENERAL LIABtLtrY------f-----l
| | cLAIMs-MADE I Xl occun
xl nrpo Ded:5-ooo
GLO939810103 t1t01t201301t01t20uEACH OCCURRENCE s1.000.000
DAMAGE TO RENTEDPRFMISFS (Fr dmurenel s100.000
MEO EXP (Any me person)s5.000
PERSONAL & ADV INJURY s 1.000,000
.GENERAL AGGREGATE s2.000.000
PRODUCTS. COMP/OP AGG s2.000,000
,or,"" [il ?FP; l-l ..o"D
c AUI
Ilxl_l
OMOBILE LIABILITY
ANY AUTO
ALLowNED l-J-lscxeouleoAUToS l^ IAUTOS
lv I NON-OWNEDHTREDAUTOS !!_.1 AUTOS
tl
25CC1348387 1t0112013011011201tCOMBINED SINGLE LIMIT
lEa accident)s1,000,000
BODILY INJURY (Per person)
BODILY INJURY (Per a6ident)c
PROPERW DAMAGElPar accidentl $
c
A UMBRELLA LIAB
EXCESS LIAB
I OCCUR
x I "*,".-"oo,
AEC5509046300 t1t011201301lo11201tEACH OCCURRENCE s2.000.000
l AGGREGATE s2.000.000
DED Xl nererurrorsl0000 c
B WORKERS COMPENSATION
aND EMPLOYERS'LlABlLlrY Y/ NANY PROPRIETORYPARTNER/EXECUTIVE T-N/A
2602008 1t011201311t01t2014v lwcsrATU- | lolH'A lTnPVlriilTs I IFR
E.L. EACH ACCIDENT s1.000.000
oFFTCERvMEMBEREXCLUDED? I Nl
(Mandatory in NH)
lf ves. describe under
DESCRIPTION OF OPEMTIONS bepw
E-L. DISEASE - EA EMPLOYETs1.000.000
e.l. otseesF - poutcv t-tt',lr | $1'000'000
A
A
Gont. Design Lia.
Gont. Design Lia.
GLO939810103
GLO939810103
11t01t2013
,1t0112013
01to1t201
011011201
2,000,000 each act
2,000,000 aggregate
5-000 deductible
DESCRtpTtON OF OPERATIONS , LOCATIONS , VEHICLES (Aitach ACORD lOt, Addltlonal Rema.ks Schedule, lf mora space ls requlredf
Proof of Goverage Only
TE
Western Automatic
Sprinkler Gorporation
2510 South West Temple
Salt Lake Gity, UT 84115
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE
THE EXPIRATION DATE THEREOF, NOTICE W|LL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZEO REPRESENTATIVE
W :vtqd^rg^o'P
ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
#s44341/M43629
@ 1988-2010 ACORD CORPORATION. All rlghts reserved.
10470
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nity
Date: 0111312014
ReceiPt #: 7o2
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:rtification 1732320
Please contact the Building Department at
(208)372-2341 for further questions about this
receipt
PAID
JAN 14 2013,
ctw oF tsFXHUJlg
24Hour Notice for insPections
Call inspection hotline at
(2081372-2344
***Credit card payments are accepted, but are subject to a3o/o convenience fee on payment amounts over $500***