HomeMy WebLinkAboutALL DOCS - 14-00455 - Certified Fire Protection Annual Safety Certificationb"
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35N l.tE
Rexburg, lD 83440
Rexburg -Modison Cou nty
www.rexburg.org
Emergency Services
Phone: 208.372.2341
Fox: 208.359.3022
CITY OI;
REXBTIRG
clu -.'------__---.._
Aneriea\ Famif Cofi*tlunitl
PERMTT#, l4-0Ott55
$100 Fee Paid: Yes/No Permit Approved: Yes/No
BY:Date:
"A tnft\ Etsten nrtfrcation permit * required to install, modzfi, maintain, or sentice all new and existingfre
extinguishers,fre suppression slstems,fre alarrz gtstems, and other hrt toft\ grtems within the CiE ofRexburg"
BUSINESS NAME:
oFFTcEPHONENUMBER, g0/- 7</-/7/c
CONTACT PERSON: {CELL PHONE #:
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL
THAT APPLY.
ffi-/<<-/m
F unn ALARM SYSTEMS - Alarm contractors shall have a minimum of NICET Level 1
Cetifications or equivalent.
*PLEASE PROVIDE CERTIFICATIONS :
{.NiCET Cetification
*Panel Certification
*Proof of LiabiJity Insurance
\A
1L AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractots shall have a
minimum of NICET Level III Cenifications or equivalent.
*PLEASE PROVIDE CERTIFICATIONS :
*NICET Certification
*Any Additional Certifications
*Proof of Liabiiitv Insurance
[rrns EXTTNGUTsHERS
-STANDPIPE SYSTEMS
-SMOKE CONTROL SYSTEMS
SPECIAI HAZARD SYSTEMS
-FIRE PUMPS
-AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
*'I*PLEASE PROWDE DOCUMENTATION OF TRATNING LEWLS,
INSTALLATION CERTIFICATIONS, LIABILITY INSARANCE, ETC. FOR ALL
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPANYNAME:
COMPANY NAME:
COMPANYNAME:
PHONE #:
PHONE #:
PHONE #:
**PLEASE LIST ADDITIONAL COMPANYAUTHORIZATIONS ON THE BACK OF
THIS FORM**
I certifu that I have tead this application and declare under penalty of perjury that the information contained
herein is conect and complete. I agree to comply w'ith all city ordinances, adopted codes, and state laws
hereby authorize reptesentatives of this city to inspect any work fot pulposes. I am either the
conttactor responsible for the work, or I represent the owner as si
/conttactofs full knowledge or consent.
acting with the-ownerts
PRINT NAM OF APPLICANT PT,ICANT'S SIGNATURE
/
DATE
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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DISIPLINES***
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FtcCERTIFIATE OF LIABILITY INSU
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATTON ONLY AND CONFERS NO RIGHTS UPON THE CERTIF1CATE HOLDER. THISGERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVER.AGE AFFORDED BY THE POLICIESBELOW TH]S CERTIF|GATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
|MPoRTANTilfthecertificateho|derisanADD|TIoNAL|NsURED,thepo|icy(ies)mustbeenaors
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lleu of such endorsement{s).
PRODUCER
Summit Insurance Group ILC
7430 South Creek Road #300
(801) 563-1131
INSURED
CERTTFIED FIRE PROTECTION, rNC
3140 South 460 West
Salt I,ake CIty UT 84115
CERTIFICATE N UM BER:cLl 4 6323 e 68 NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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.
A
TYPE OF INSURANCE POLICY NUMBER LIMITS
GE
x I ao"".^",o, oaNERAL LrABrLrry
l-l "*,"""oo, f xl o."u*r-->o 2c217834-cor.t/L4/20L4 t/14/2Or5
EACH OCCURRENCE s 1,000,00C
I U KENI EUS lEa oeurene)s 300,00C
MED EXP (Anv one Derson)$ 5,000
PERSONAL & ADV INJURY s 1,000,00(
-J GENERAL AGGREGATE $ 2,000,00(
GEN'L AGGREGATE UMITAPPLIES PER:-l ,o..,." I x I rP; l_-l .o"PRODUCTS -COMP/OPAGG s 2,000,00(
E
A
AU'IOMOEILE LIABILITY
ANY AUTO
ALL O\^NEDAUTOS
HIRED AUTOS
[--l scHeour-eo
L-J AUTOS
| | NONO\ /NED
l__l Auros
tt
r10-2c217834-PEX ,/L4/2014 ,/L4/20Ls
IEDSINGLE LIMI s 1,000 . oocxBODILY INJURY (Per peIson)D
EODILY INJURY (Psr accident)D
ljninsured motorist combined $ 1 nnn nnr
B
x UMBRELLALTAB lXloccun
EXcEssL|AB I l"'o'r"-ro.o
3E 080850542 i/!4/20L4 /!4/2075
EACI.I OCCURRENCE s 4,000,00C
AGGREGATE $ 4,000,00C
DED I I RETENTIONS $
WORKERS COMFENSATION
N/A t666497 /L4/20r4 ,/L4/2015
x litAlu-y I lirtT!JI H.trD
ANy pRopRtEToFypARTNER/EXECuTtvE t-ioFF|CER/|!4EMBER EXCLUOED? l_l(Mandatory In NH)
lf yes, descdbe under
DFS(]RIPTION dF r)PFPATInNa hcltu
E.L. EACH ACCIDENT $ 1-000.oot
E.L. DISEASE - EA EMPLOYEI s 1.OOO-OOt
E,L DISEASE . POLICY LIMIT 1 .000 .00c
A ERRORS C OMMISSTONS
INI,END I{ARINE
acoLls63L77
)86605D7 66953
i/L4/20].4
;/L4/20r4
i/74/20L5
i/r4/20]-5
GENERALAGGREGATE $1, OOO, OOC
LEASEO/RENTEDEQUIP. $50,00C
OESCRIPilONOFOPERATIONS/LOCATIONS/VEHICLES (AftachACORDlOl,AdditionalRemarksschedule,lfmorespaceisrequlredl
TE HOLDER
****INSUIIED COPY*****
SHOULD ANY OF THE ABOVE DESCRIBED POLICTES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NONCE WLL BE DELIVERED tN
ACCORDANCE WITH THE POLICY FROVISIONS..
AUTHORIZED REPRESENTATIVE
ifalk Hunter MRH/ACSD
ACORD 2s(2010t0sl
lN3025 trornnrt or
@ 1988-201 0 ACORD CORPOMTION. All rights reserved.
Tha ACOPD nama and Innn ara roniefarar{ marke af ACOPF!
Xpress Bill Pay - Payment Processing httns ://www
lessbillpay.comicommon/paymentlrrocess.php
City af Rexburg
35 Northlst East
Rexburg, lD 83/t40
208-359-3020
t:trfY cjrl:
REXSTTTG{w -*--'- -
,qr*:i*a? li+ixl$' Lir:x*:tr*ry'
XBP Gonfi rmation Number: 4Q247 54
r"99l.nlj
14-00416
14-00455
Billing Information
Dustin Moser
.84115
llem {mou1t
TOTAL: S21A.A0
Transaction taken by: amanda
l Transaction detail for payment to City of Rexburg.Date: 10/08/2014 - 2:11148
Transaction Number: 29395276PT
Masterca rd - XXXX-XXXX-XXXX-251 4
Status: Successful