HomeMy WebLinkAboutALL DOCS - 14-00089 - Shilo Automatic Sprinklers Annual Safety Certa)
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35N I.'E
Rexburg, lD 83440
Rexburg -Mqdison Counly
Emergency Services
Phone: 208.372.2326
Fox: 208.359.3022www.rexourg.org
SAFETY SYSTEM CERTIFICATION PERMIT APPLI CATION
"A tnft\ slsten certtfcation permit is required to install, modtfi, maintain, or service all new and existingfre
extinguishers,fre suppression ys.tens,fire alarru slsterns, and other lfe safeE sltstens aithin tbe Ci\ of Rexbury"
BUSINESS N
oFFrcEA-DDRESS. /4 t/f,
oFFrcE pHoNE NUMBER, "-laa - lLL -Oqa
coNTACT pERSoN: =/t-^, eru. cELL pHoNE #,bt-/fup-@oc
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT. CHECKALL
THAT APPLY.
-FIRE AI-ARM SYSTEMS - Alatm Contractors shall have a minimum of NICET Level 1
Certifications or equivalent.
*PLE,ASE, PROVIDE CERTIFICATIONS:
*NICET Certification
€.Panel Certification
{.Proof of Liabiliw Insurance
./ *NICET Level II required for design work
y AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a
-i"i-.r- of NICET Level I Certifications or equivalent.
i.PLE,ASE PROVIDE CERTIFICATIONS:
{'NICET Certification
{.Any Additional Certifications
{.Ptoof of Liability Insurance
.:. NICET Level II required for design work
-FIRE EXTINGUISHERS
N.Proof of Certification & Training
AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
/ €.Proof of training for commedralyool<tngheads
,/ STANDPIPE SYSTEMS -JsTncIAL HAzARD SYSTEMS
SMOKE CONTROL SYSTEMS
-I6IJ(NPUMP
'l'Y o F
REXBURG
Americas Family Connunity
***PLEASE PROVIDE DOCAMENTATION OF TRAINING LEVELS,
INSTALLATION CERTIFICATIONS, LIABILITY INSURANCE, ETC. FOR ALL
DISIPLINES*4c*
I ceti& that I have tead this application and declate undet penalty of pe{ury that the information contained
hetein is cotect and complete. I agtee to comply with all city ordinances, adopted codes, and state laws
telating to the installation, modification, sewice, and maintenance of new and existing life safety systems. I
heteby authorize reptesentatives of this city to inspect any wotk fot compliance purposes. I am eithet the
contractor tesponsible fot the wotk, ot I reptesent the ownet as signified above and am acting with the ownet's
/conttactot's full knowledge ot consent.
DATE
PERMIT VALID UNTIL DECEMBER 31OF THE CALENDARYEARAPPLIED FOR.
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PRINT NAME OF APPLICANT APPLICANT'S SIGNATURE
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ACORb@ cERrFl?or. oF LrABrLrry rNSUt*",
CERTIFICATE NUMBER:13-14 ocr MASTERCOVERAGES
DATE (Mf,t/DD/YYY/)
lo/r/2013THIS CERTIFICATE IS ISSUED AS N rVrArr
::lIll"ilt^""".t"t,IP^lStlTTl:r,v.SlI:-o^Eo^AIry_ELJ ty_Er{o, exrENb oR ALrER rHE covERAGE AFFoRDED By rHE polrcrEsBELow. rHls cERrlFlcArE oF TNSURANcE DoES Nor coNsrrurE o "oi,rno3i';;ift;r'"t;;T:;,il',"r:"r'*?"iJl,'Xil;;l;|;REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: lf the certificat"
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certiticate does not confer rights to thecertificate holder in lieu of slrch endorsement(s).
ISU Cunnington & Associates
P.O. BOX 429
Eagle ID 83616
Brenda EJ-1is
(208) 672-6180 (208) 3?5-8280
brendaG cunningtonins . com
TNSURERA Nautilus Insur r-7370INSUREO
Shilo Automatic Sprinkler fnc
1,224 Ltt]n Ave N
Nampa rD 8368T
eNational Union Fire fns. Co
ttsdale Ins Co
o:Ins. Co. State of pennsvlvania 19429
REVISION NUMBER:THIS IS TO CERTIFY THAT THE POINDICATED' NOTWITHSTAN,DI-]\TG.$Y REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUT.,TCNT WITH RESPECT TO WHICH THISCERTTFICATE MAY BE lssu-ED oR l'4AY PERTAII'1, rHL tlsun;,'^tcE ATFoRDED By rHE poLrcrEs oesciiaeD HEREiN rs suBJEcr lo ALL rHE TERMS,EXOLUSIoNSAND coNDlrloNs oF sucH poLtctes. Lt,tarrs snowru MAy HAVE BEEN REDUcED By pAlD cLAiMS.
POLICY NUMAER ,YYI LIMITS
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I "o"*a*a,oa cENERAL LrABrLrry
T-l .*,"r-"ooe f xl occun
I $s,ooo oeaucr-ir/po
l--------
N'L AGGREGATE LINIIT APPLIES PER.
lpor-rcvlxl?5P; I l'-
rcP 200386702 ) / 30 /20L3 / 30 / zOL4
EACH OCCURRENCF s 1,000/00(
t IURTNIEI)ES lFa occrrrr!s r00.00C
N.4ED EXP (Anv one oerenl $ 5,000
PERSONAL & ADV INJURY s 1,000,00C
GENERAL AGGREGATE s 2,000,000
PROOUCTS. COMPiOPAGG s 2,000,00(
s
B X
x
ANY AUTO
Abr.3yro l-l s*roureo
HTRE'AUTos lx] Igi"dJt."tl
rA 160?592 /L/2or3 /L/2074
JMBINhD SINGLE LIMITa accrdent),000. o0c
EODILY INJURY (Per person)s
BODILY INJURY (Per accidmt)
PROPERTY OAMAGE(Per accidenll s
sltUMBREUALTAB l*joccu*
ExcEssLlAB I lcr.ltNs-nrnoe
MSo027666 ,/30/20L3 / 30 / 2OL4
EACH OCCURRENCE 3,000,00c
AGGREGATE s 3/000,00CoeO lx IRETENTtoNs 10,00,sDAND EMPLOYERS' LIABTLITY
ANY PROPRIETOR/POO*'A""",,U' 14OFFICER,/MEMEER EXCLUDED? I I([4andalory In NHI
ll yes, desqlbe underDESCRIPTION OF OPERAITONS berow
N/A rc 3621182 (Aos)l/L/20L3 / 1/20L4
wcsTAru- | loTH-fnPVlll/lTql lco
E,L. EACH ACCIDENT s 1,000,000
E.L. DISEASE - EA EMPLOYEs 1.000. o00
E.L. DISEASE. POLICY LIMIT s 1.ooo-ooc_1Profess ional Liabi]-i- tw
Retro DaL 9/30/2OO9
tcP 200386702 / 30 / 2013 t/30/20LA peroc@ren€ 1,000, OoC
dedrclible 5, OoC
oEscRlPrloNoFoPERAT|oNs'LocATloNSIvEHtcLEs (AttachAcoRD101,Additionat Remarkssdredute,if mqespaceisequtred)Pl:oof of Coverage
CERTIFICA OLDER
AcORD 25 (2010t05,t
lNS02l onrnnsr nr
CANCEL
o 1988-2010 AcoRD cORPORAT|ON.
Tha AfIl.)AD nrmo rnd Innn ara ra^icfar6d m:rt<c nf dr_-npn
Proof of Coverage
SHOULOANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED AEFORETHE EXPIRATION DATE THEREOF. NOTICE WILL BE DELTVERED INACCORDANCE WtIH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
renda EI-1is/BRELLT
-€-.t,.
All rights reserved.
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Date: 0310412014
Receipt #: 1254
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>rtification
Project:
Address:
Shilo Automatic Sprinkler Annual
Safety Certification
Permit #: 14-00089
Permit Type: rtResAFETy
1732320 100.00
Please contact the Building Department at
(208)372-2341 for further questions about this
receipt
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24 Hour Notice for inspections
Call inspection hotline at
(2081372-2344
***Credit card payments are accepted, but are subject lo a 3o/o convenience fee on payment amounts ov€r $$99***
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