HomeMy WebLinkAboutALL CERTIFICATES & RECEIPT - 14-00005 - Fire Services of Idaho Annual CertificationU
E
H
H
U
U
F]
H
o
Hw
E
H
4
Ho
F]
Hcz
Ed
l_t .
E
o
C)a
)J
co.H
Ct O) .;(t H r-r.
C c)ct
crO
Pt=Q\'lDo
HHHr
l-a
mry P..
C,3 9.. FD
T9 F).
Oo
t\?'
p
:
ry
H
N
H
reE
O :fh
H
f'Jttr )tr
o
o
o
Av
gr
*#:.I l-'{ .+x-:
+ crl-l -
.E.f L.,\J {
i-r,i .35 t-a '::
E 'r\)
3n.s kJ
(n
z
€
H
L^J
\
r.
F.1
F
F|i
H
-
l{l
r
Ll
o
E
H
ritrJ
g\, .Flt5
t9
'r
Rexburg -Modison Counly
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022www.rexourg.org
SAFETY SYSTEM CERTIFI CATION PERMIT APPLI CATI ON
*A tortA ystum certifcation perztit is required to install, modtfi, maintain, or senice all new and existingfre
extinguisbers,fre suppression gtstems,fre alann slstems, and otber lfe safe4t ystens aitbin tbe Ciry of Rexbury"
BUSINESS NAME:
OFFICE ADDRESS:
OFFICE PHONE NUMBER, WC
CONTACT PERSON:CELL PHONE #:
PLEASE IDENTIFY SYSTEMS TO BE COYERED BY THIS PERMIT- CHECKALL
THAT APPLY.
Fffne ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level l
Cetifications or equivalent.
€.PLEASE PROVIDE, CERTIFICATIONS :
*NICET Certification
{.Panel Certification
{.Proof of Liability fnsurance
{.NICET Level II required fot design work
ZLXUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have t
minimum of NICET Level I Certifications or equivalent.
{. PLEASE PROVIDE CERTIFICATIONS:
.'NICET Certification
.1. Any Additional Certifications
*Proof of Liability Insurance
* NICET Level II required for design work
,/-TTne ExTINGUISHERS
*./ t?.Proof of Certification & Training
7--ruroMATrc FrRE EXTTNGUTSHTNG sysTEMS FoR coMMERCTAL
COOKING
{.Proof of training for commetcial cooking heads
-STANDPIPE SYSTEMS -SPECIAL HAZARD SYSTEMS
REXBURG
Anrc r i cal Fa mily Cofi ffi un ity
,IY OF
35N l,tE
Rexburg, lD 83440
a;i-t'27/
-SMOKE CONTROL SYSTEMS
***PIEASE PROVIDE DOCAMENTATION OF TRAINING IEVELS,
INSTALLATION CERTIFICATIONS, LIABILITY INST]R,ANCE, ETC. FOR ALL
DISTPLINES***
I certi$ that I have tead tlris application and declare undet penalty of periury that the information contained
hetein is cottect and complete. I agtee to comply with all city otdinances, adopted and state laws
relating to the installation, modification, service, and maintenance of new and safety systems. I
I am either theheteby authorize reptesentatives of this city to inspect any work fot
contractor tesponsible for the wotk, ot I teptesent the owner as acting with the ownet's
APPLICANT'S SIGNATURE
,,== l'} I 76 l,-'7
DATE I
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDARYEAR APPLIED FOR.{.{.*{.**************************************************************{.********x***
Itq,
PRINT NAME OF APPLICANT
DEC/27/2013/FRI 12; 47 PM
,iQo' ,,rEr
Muiual Insurance FAX No. 20823i971 6 P, 001/001
.ACOR
\€''CERTIFICATE OF LIABILITY INSURANCE DATE (MM'DD'YYYYI
6/26/20]-3
TH]S CERTIFICATE IS ISSUED AS A MATTER OF II{FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFTCATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE |SSU|NG TNSURER(S), AUTHORTZED
REPRESENTAIIVE OR PRODUCER, AND THE CERTIFICATE HOLDER,
|MPoRTANT:1fthecgrtificateho|derisanADD|T|oNAL|NsURED,thepolicy(ies)mustbeendorsed.ttsoe@
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 lieu of such endorsemenl(s).
PROOIJCER
Mutual Insurance Assoc,, fnc.
1575 Baldy Ave
Pocatello ID 83201
i|ili?'' M-rtual Insurance Assoc., Inc.
lfi3.to.o,, (208)237-9696 |lil", eoar2sl-s6s7
E.MAIL
AODRESS:
INSURER(S) AFFOROING COVERAGE NAIC '
TNSuRERA :Uaited Specialty Insurance
INSURED
Fire Sewices Of Idaho Inc.
610 lrraUard Ave
Chubbuck ID 83202
TNSURERB:Ciaci.nnati Insurance Co.1O677
rM;uRERc:Idaho State Insulanc.e FuDd t6L29
IiISURER D i
INSURER E
IASURER F .
COVERAGES CERTIFf CATE NUMBER:201 3-2OIA Master REVIS,ION NUMBER:
THIS IS TO CERTIFY THAT THE POTICIES OF INSURANCE LISTED BELoI/v HAVE BEEN ISSUED To THE INSURED NAMED ABoVE FoR THEfotICY PERIooINDICATED, NOIWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIOT.I OF ANY COT.ITRACT OR OTHER DOCUMENT WTTFT RESPECT TO W{ICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE EEEN REDUCED 8Y PAID CLAIMS.
NSR
LTR TYPE OF INSUMNCE POLICY NUMAER POLICY EFFIMM'MTYYYYI
frM LIMITS
A
GE
x
!ERAL LIABILITY
I aorrr"a^ .ENERAL LrABrLrrY
I lclnrugvnoE lXloccuR
r_
,sA4031553 ,/25/2073 /25/2014
EACH OCCURRENCE g 3,000,00(
UAMAGT IO RIN ItsI.)
PRFMISFS lFa dcdiren.el $ 100,00c
MED EXP (Anv one oersonl $ 5,00c
PERSONA & ADV INJJRY o 3,000,00C
GENERAL AGGREGATE 4,000,00c
GE
X
{,1 AGGREGATE LII\,4IT APPLIES PER
lpolrcvl I-A$ | lroc
PRODUCTS - COMP/OP AGG $ 4,000,00c
D
B
AUTOMOBILE LIABILITY
I ^, orro
lAb',3fl'o E isi5g'*"
I n,*.oorro, I x I lP,l;?*ooI -',---'ttl
rPP0083695 /23/2073 t/25120t4
COMtsINtD SINGLE LIMITlFa aeidentJ 1 .000 .000
BODILY INJURY (Per person)
BODILY INJURY (Per aeidert DxPROPIR I Y DAMAGElPer acodent)
Medical oawents $ s. ooc
B
x UMBRELLA LIAB
EXCESS LIAA
x OCCUR
CLAIMg]VADE ;PP0083696 i/2512013 i/25/2014
EACH OCCURRENCE 2 ,000,00c
E 2,000,00C
n.n I lo.rr*r,nr* 10,oo(vcWORKERS COMPENSATION
AND EMPLOYERS'LTASIL|TY Y' NA\Y PaOpRIETORPART\ERiE)€CUTTVE l----"1OFFICER/MEMBER EXCLJDED? I I(Mandatory in NH)
ll yes, descr be under
DESCRIPTION OF OPERATIONS below
N/A 74857 /t/20\4 /L/2015
x l#!"slfrl Y" I loJS
E L. EACH ACCIDENT s 1 .000 .000
E L, DISEASE - EA EMPI OYFI $ 1.000-ooc
E.L DISEASE. POLICY LIMIT $ 1.000 _ 00c
OESCRPIION OF OPEMTIONS, LOCATIONS , VEHICLES (Attach ACORD 101, Additional Remuks Schedule, it morc spac. is requircd)
(20er 359-5022 amandasGre:cburg. org
City of Rexburg
Attn: Amanda
35 Nortb 1st East
Rexburg, ID 83110
S}IOULO ANY OF THE ABOVE DESCRIBEO FOLICIES BE CANCELLEO BEFORE
I}IE EXPIRATIOII OATE THEREOF, NONCE WILL BE DELIVEREO IN
ACCORDANCE WITH THE POLICY PROVISTONS.
AUTIORIZED REPRESENTATIVE
Loren Azzola|BJH
ACORD 25 (2010t05)
lNS025 lzoroosl or
@ 1988-2010ACORD CORPORATION. Ail righrs reserved.
The ACORD name and logo are registered marks of ACORD
ttr
(n
{nlt\il
\c
gp
!(fl
,f
I
(\l
t{
Ir'l
M
dr--s
x
co
.trF
I
r|i
\E|'s
ulgt
&
u1!o
,FI
tt)
{ll
a
\c
n
.i
t
+r
tt)
€':i
.5
3
iin
rt
f\
&l
wa
{-}
(q
/1
$
ilb
Iq
*r(
&ry&
o
Lta
; a F
dH*.FSE. S H?: cn U5qp {E (J (n€.f;?{,9 F;EFSiEI T:*t;i >.HlSt.gE a'l FtrE-tsEJ98
ani 5 $
,$t FF''tr{g E rc
f;)r{ f;-cG
strIUuE
$
{
l|-osIItrE
$
o
{F
{!t(\t
€rf!
frl
..!{
(a
':!
HPk' :r!
z
2
6xtrr
aztnJ
{f,-|
f?'t
'?lo;u
nmfr3
3n
I6z
a
mz,g
z,mnrg
z,n
*{
nfn
fzorosm
{/l
@
"t)
"{
L,J_
)r,{}
'l
rb
tu
ry
r(}
fti
'{
\,..|
:)
1l:
i.o
t_, I
XS ;7 : in -t H
*L -- .,'f; F =gz -r
fiE := : E f.6
;t ?: p I5 {
zrn € ffi z(} C '/ r'^"
: n F -v j5a 'r= a ',,t
5S *: ril \r *t
,{! ;.,/ c| $.-.R=/-r
rn'-t-.Tp - '$ odE :- { {=l = -59 - n
il ?: f/^) Ii ":
m> .- Q>J zr.^ o --1m* -: Af?l{o ---
11 -n :lo:r {-3r't1o :-c
qi; :-<q ./
*l ffi
Sxrnz
ZYqF
li rtr
58ff! ftt
t4
$
q)
.{
v,o
Eq)q
o
(J
$
q
o,4aq'
TL
t"lj
.l(
$E
\\N
\
Q
ot
$ Be
f; E€t^ Eg6 F8
E Eso q E$fiP=" i
s5gigiggg$$
ir F tsE
* €tE Egs g$
F SF
4
t:
tr{.q{}
t?F
€+!.
,t
!t
RR
F.J F\sI$Esfi
ii
*Eacg'€
.:$
S .i=FT
rq
o(\|
F-
ru-{]
E}
(uq
g
o
b8
H, aEE E_€E ,fE ;c"o H.9o *
E : $F's
-i f.r O() tr
f ed Fe Fs P crF a
9?? E iiX
$ s n$ HE $r$fsia F
3
Eq)q
O)IEtsfsts
\,*
q)
f .t€
t r*O
LD -F
LU
\rGd(/)E(E
EiE9=ovr-\u
R9EIF.\SEF(Uo\?iE Xg- x\>-6(Ex.H PEoi*a
-c;tSE }.5Eg€ E:.i,F c )6-.\r^-=->vJ=: !u>'s;<-U 6tg^\o
EESo cqo\od
€
oct,
(E
ooE
o
g
.Eocts
r=;\E e ;f-.S"E AH+c;.-?=g;i:q 3E -.:E'.E€i;'fr9*.*E.E=;gg;
s 6 70r{ -: 6 E\yt g, Oa
aiE3(t,
o
IL
tr
G'
=(U
oot.
No
It.
q
t
b)*S
q
q
I*s
I{
r\t
oo
NN
of ot
bb(u(!
(l)Q)
o
*8otrp€.= !u
Fq ,f
.eogs
8bEq)-tro)
(I)oQ
(t) O-F
Fq)
$
ON
([
(D
tL
o
Go
co
g
axul
b :9u EE- po
E 6Eteoqr 6E' g'd E(DON=o)e : +E 3^ 6 ao !5.9 ei se E(E -o ii _ q)
Es*CL F',=O^..8 :E Ffr*s s eE .i.rf 3;: EE A
i L 3P t - ts,;3€E c!3 S'Fg^3FYB Foilod Ea F
o
Rx
€
a)
o
\rt,
\Frltl
]*
Io1lo
\
n
o- 5
l:rr(D€a' N
€a #E+ S9"8 Esd q
o5' =
Po l!SS 6
fi$s S rr
e-o Fi !t cr d
}IF DE U,
s$i ig. a s 3 =rr=i'5trl'FE*g:C $E $ * o F$Fi i$ t;;t3*;'F;
-
$s;1< c- o o ORd: 6'='rdH :- tsd * f,
$=. =8_d E
lS g
n\a
Xia Iv6r-P3 g,
do
eo
m{{E.
!, :'
6', (o
3c'
oPqro
!q
Tl 'Tr
ooqq'triqg
9r JJ|
88
NA.
\
\
N
\
s
x
lrl
TloU,U,o
o
I
b
o
-*r
CNo
6'oU,I
o
e)0)(r,
!
s
o:
\
bo
>r
€
=\rFo
]-s\r
$a
v
o-l 5
l5 ct
ta' N
€a *E* $9.8 Es6 Eo5' =
Po Is3 dq3- u,N$s 5 +a-O S ! o O>a.q ;9isg fr: g
S*: =3' F e e =5gr 3; rF i'*
$Es gfi q s E 3*rE te €.; 3a*$fi "F; -
$sil< a. ut o oRds rE'3'-\=.-+$d ; BrE q il$=. --
8{ E[S e
RN. ;+D IY$ 5P: q,
do
eo
md€8.
q, ='
6'(o5cls9!ro
!D
T] TIOo'qg
triHg
Jtt -(.rt
N) N)Oo
\tA
\
\s
\
F*lx
TIoC'qo
&
I
U=.$oo.\
ao
S
oaI
o
x.
o)6
!
!
s
d
iv
b
Ltrt ut tllnlurt,
f'Hltr sl: I lf{t .:LF:"/.tLLb ur rtrHftu, lf{L
UHlLl UI/Un/ft nf /'UlUn./L.l'{lt{
iiiiEr it;1.1;i? F:ti-iEiFi ii'-t;.i19,lii
HFF NI!I ,J!dHF:
tG
lunity
Date: 0110612014
Receipt #: 688I rltli ritPT FiFit i'EFii'tiT
L.HLLT., HNUUfl I
I nttlLttl
L.HHT{Ft
FEftHiT #i4[C[[5
THAH!.i TOU Ai,IIi HAVT fi Hi[T IIAY
IUIJ.LI'd
U. UU
Address:
Fire Services of ldaho Annual
Certification
1732320
Permit #: 14-00005
Permit Type: rrnesAFEry
;ertification
Please contact the Building Department at
(2OB)37 2-2341 f or f u rthe r q uestion s a bout th is
receipt
$100.00
pAttr
JAN 6 ZO14
CITY CIF REXBLjRG
24 Hour Notice for insPections
Gall inspection hotline at
(2081372-2344
**.Credit card payments are accepted, but are subject lo a3o/o convenience fee on payment amounts over $500***