HomeMy WebLinkAboutALL DOCS - 14-00008 - Firewise, LLC Annual Safety Certificationo,
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pursuant to the ldaho insurance laws byan insurer not licensed by the ldahoDepartment of Insurance. There is nocoverage provided for surplus lineinsurance by either the ldaho Insurance
Guaranty Association or by the ldaho Lifuand Health lnsurance GuarantyAssociation.
Policv NO FLAT CANCELLATION
Perio'd: From 02/L3/20r4 to o2/13/2015 at12:0'l A.M.StandardTimeatyourmailing addressshownBusinessDescription: sALEs AND sERVrcE oF FIRE EXTTNGUTsHERs Taxstate
E Trust [] Ltmtteo Liabitity Company (LLC)including a Partnership, Joint Ventur" or. Ltd)
above.
ID
COMMERCIAL LTNES
NAUTILUS
New
POLICY . COMMON POLICY DECLARATTONS
INSURANCE COM PANY
Scottsdale, Arizona
Named Insured and Mailing Address(No., Street, Town or City, County, State, Zip Code)
Transaction Type:
Reneural of Policy #
Rewrite of Policy #
Cross Ref. Policy #
NIC Quote #
FIREWISE, LI,CDBA RYAN HAGGE541 COUNTRYSIDE
REXBURG
KEVON FARRERINSURANCE
ID 83440-
AGENCY, INC.
MT By
. .JC,/ MT
Inspection Ordered
frYes INo
Agent and Mailing Address Agency No. 02s00 _ 0o(No., Street, Town orcity, County, State, Zip Codc) -
Big Sky Underwrirersa Division of HulI c Company IncPO Box 3557
Missoula, MT 59806
Form of Business: ! Individual I partnership [ .toint Venture
fl Organization, including a Corporation (but not
IN RETURN FORTHEPAYNIEIITOFTHEPREMIUM, AND SUBJECTTOALLTHETERMSOFTHIS POLICY,VVEWLL PROVIDEYOU THE INSURANCESTATED IN THIS POLICY.
12 WEST MAIN
REXBURG, ID
Countersigned:
SUITE 2
83440
MISSOULA,,
02/r4/20r4
THESE DECLAMTIONS TOGETHER wlTH THE COMMON POLTCY CONDITIONS, COVERAGE PART DECLAMTIONS, COVERAGE PART COVERAGEFoRM(s)AND FoRMsAt{D ENDoRsEMENTS, lFAt{Y, lssuEo ro roau nienrrxEneor, colrrpr-Eriinieaove NUMBERED poLrcy.
Includes copyrighted m ateriar of Insurance seMces office, rnc., with its perm ission.
THIS POLICYCONSISTS OFTHE FO
THIS PRElvl IUM MAY BE SUBJECT TO ADJUSTM ENT.
ISINDICATED.
PREMIUMCommercial General Liability Coverage part $ s.5L4. oo
$
$
$
s
$
$Tax & Fee Schedule
POLICY FEE
INSPECTION FEE
STATE TAX
STAMPING OFFICE FEE
r /5
25
9
TOTAL ADVANCE PREMIUM
33 Minimum&Deposit
7L TOTALTAXES& FEES
29
I s,srq.oo
$ z65.00
TOTAL 779.00
Form(s) and Endorsement(s) made a part of this policy at time of issuJRefer to Schedule of Forms and Endorsements.
is applicable
E001 (04/09)ORIGINAL
35 t'l ,'' E
Rexburg lD $UA
Rexburg -f,fiodison Cou nty
Emrgency Scrvlcer
Phonei 208-372.2326
Fax:208-359.3022www.i'ex0urg.Org
SA.FETY SYST4M CERTIFTCATTpN PERITIT APPLTCATION
*A mlig ytt*tt wtifmtion panait is nqfind to install, nodfi, naintain, w wd* atl mv and *istitgif*
*titgrislxx,fn ;,rlippnl.rion systuat4fn atatw gtskms, a*d other llfc mfcty $stans pithin lhe Ci$ of fuxrrq"
BusINEss NAII{R FTREWTSE LLc . Parcek-
OFFICE AI}DR"ESS:541- Countryside Ave. Rexburg, ID 83440
CIFEICE P}{ONE NUMBER;(208) 227-3993
CO1.1'1ACT pERSON: Ryan Hagge .- CELL PHONE #:
PLEASE IDENTIFY SYSTEMS TO AE COVERED BY THIS PERMIT. CHECKAI.L
T}TAT APPLY.
*_FIRE ALASIVI SVSTEMS - Ahnn Contflcrsrs shall have a minipum of NTCET f-cvel 1
Cenift:a dons or eguir"alrlnt,
t PLIiASS, pAOVtI)g, CERTIFICTfL'IONS:
+NfCItt' Cenificetion
*Panel Ccrtificrtion
taPrnof of I i{bilry lnsurance
&NlCE.l'Level II requircd for design wo*
_AUTOMATIC SPRINKLER SYSTEMS * Fir* Sprinkler ContrectotE shall heve a
midmum of NtrCtil- Level I {lcrtificerions or equivdcnr
S PLEd\SE PRO\IIDE CE RTIFICATIONS ;
t NICF-T Certriication
ttArry Additionel Certi fi ceuons
*tsroof of Liehility Insurnnce
.:. NI{:ET l,evel II tequred for desrgp worh
X FIRE EETTNGUISHERS
,rlPrcof of Certificetion & Training
-AUTOMATIC FTRE E:{TINGUISHING SYSTEMS FOR COMMERCIAL
COOKNG
&Proof of tremtng fot comrncrcial cooking heeds
gl l'Y {J tr
REXBURG
ft'|
6p1g159t gparily (i t4t r t tutri g
-_$TAIr{DPTPE SYSTEMS
-. SMOKE CONTROL SYSTEMS
-SPECIAL TIAZAR.T} SYSTEMS
-FIRE PUMP
-t -
*#PI {gE' PROI'/,DE DOCTJMENTATION OF TNAINING I,'E'UEI^$
TipffiTAl;IArION fjE&TIFICdfiOj|i,S, f,IABILITy.frV.f Ui?,'il\rCJq' ETC. f{tn fiI
DITSJP;IJVES***
I ccrtif rhrt I hmc rcrd this application and declnlc uoder penrlty of periury thrt tht infottrdon cotrirind
hu,ein ir erfircst r*d cooplere. I *grce to comply *'i$ rl! city ordiorncer, rdoptcd codca, *od ctelc lrn'r
rrlrd*t fo $c inetalletion, modificetion, rcffim, end maintensncc of new end exicting lifc **fety sy*temr' I
bcreby rufrotirr lepre*cntrtiver of rhir city to inepcct any work for complienc* putporce. | *m eithcr thc
*ourctor ;grpoocible for 8re worh or I eprc*ent rir o*rrcr r* eigoificd ebovc rnd ro ectiag wirt Ae ol*nct'a
/contnclofa ftl| fnoailcdgl oi contctrt
Ryan ,-T. Hagge
PNINT NA}IE OF APPLTC* TT
1./7 /20].4
APFLTCAIVI.'S SIGhI/ TURE
DATE
PEAMIT YALTN TTNTIL DECEMBtsR 31 OF THE CALENDAR YEAR ITPPIJED FOR.
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:uRs uANr ro rH E rsAH; ;;;; iiniii **,)Y AN INSUftER NOT LICENSED BY THE
DAHO $EPARTMENT OF INSURANCE.
rHERT 15 NO COVTRAGE PROVIDFD FOR;UftPIUS LINE INSUfiANCT SY EITHER THE
DAHS INSURANCE €UARANTY
\SSOCIATION OR 8Y THE IDAI{O TIFF AND
{EALTH INSUftANCE GUAftANTY
\SSOCIATIO|'I. Jailet Beaver #321996
Sentury-S u r.ety Com pa ny
{65 Cleveland Avenue
Westewlfh, Shto4t0S2
fr{{fi,f.eilil0
*w!fl .c{rtturytu rfiy.cam
_ _g_Qlr-ttERctAL LTNES POLTCYCOMMOH POUCY DECLANNTIONS- -iirucy Noitcp- - tetre^ " " --i
NAMHD 'NSUREN ANO ADDRE$$;Sirow*se LLt53S3 S, 1S50 W
Rexburg t*83440
Commorcial Generaf Liability Coverage Fari
Folicy Fee
Inspection feo
State Tax
Stamp Fee
2.s % of rhe Policy premi*m in fuffy eam*d as of tire effoctivs
_ date af lhis policy and is not eubject lo return or refund,Service af $ult (if fcrm CCp 29 1O is ettach*d) may bo mmdo upon:
JH lnsurance Servicss
120 E.311 nt lC, 838&4
{s)and Hndors*ment{r} made a
See Attnched $chedule of Forms, CIL 1$ 00b 02 0A
COMFANY FIEFRE$ENTA?IVE:
JH Jng*ranc* $nrvices
1?0 F. Lako St-
$uile 311
$andpoinl til g3S$4
Itrl yt/lTHtSU tfllttnfoF, this Cornpeny hE* sxe{rrtsd 6nd sttsflsd
Agnnt of thir Company at the Agency hereinbef*r* mentioned.
04/sst2012
New
CODH NO.;6061AINSURED,S AGSNT;
$rafi Lake Insursnce Agency
F.O. 8ox 3278
((3'or-icV prnion:- Fr$#:0tt6:z.0iz ?sj0#6-:0ia st 1r;ofA:rrn s-."nai,ro?,ffi*ffilfiui|UmAA*ff1*rffil%;"s. --
Business Oe*cr*ption; Fire ilxtinguishers
Q fndiv*dual $ Joint ve*ture Q Fertnoffihip @ Limhed Lieb{ity compony (LLC) Q organirslion {other than panne€hip. LLs or Joint venture}Iil* HETURH FOR THE PAYTI'EHT OT TflH PREHIUII, AHN $UBJTCT TO AtL T}IE ThRf,I$ OF THIS POLICY, WE A6REEWITH YC1J TO PNOVqETHE IHEURA}*C* A$ STATEN IH THIS} POLICY.THls PoLtcY col{slsrs oF T}l[ Follflfifl]lbToVendce Piirs-Fb* ilttmtcx A pftEinutn t$ u'lotcATss. TlftsPREiIIII]II MAY ET SUBJTST TO *DJUSTIITEI{T-
PREiIIUII*
$1,314.00
TOTAL
$100.00
$150.00
s23.46
$3,s1
$1,591.37
these prEs€*t*; bu! th*$
Secretary
poltcy shall not be valM unheu couniersigned by ths duly Aulho.irod
*:"-&!;:,:n
cscP 1{101 05 8s
President
Fage 1 of 1
Xpress Bill Pay - Payment proceuing
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City of Rexburg
35 Northlst East
Rexburg, lD 83440
208-359-3020
. 4Ll fal, Frinter e f}wrwqwwa*{:
Date:0110712014 - 4:18:25 pM
Account# ftem
Billing Information
FIREWISE, LLC RYAN HAGGE
.83440
Item Amount
TOTAL:
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