HomeMy WebLinkAboutALL DOCS - 14-00093 - Rock Creek Fire Protection Annual Safety Cert35N tdF
Rexburg, lD 83440
Rexburg-Modison County
Emergency Services
Phone: 208.372.2341
Fox: 208.359.3022www.rexourg.org
REXBURG
cts' -**-
Ante riils latniiy Connunifu
PERMIT#:
$l00 Fee Paid:BV.rE
Date:
"A toft\ s-ltstem nrtifcation pernit is required to install, nod{1, maintain, or seruice all new and existingfreextinguishers, fre suppression ystems, fre alarrn Estems, and otber life safeE sjtstens witbin the Cig of Bcxburg,'
BUSINESS NAME:
OFFICE ADDRESS:
OFFICE PHONE NUMBER:
coNTAcTPERSoN: Sl,unoR y'n-o,.4 CELLpHoNE #: &a.,+le_
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALLTHAT APPLY.
n rlnE ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level 1Certifications or equivalent.
.t. PLEASE PROVIDE CERTIFICATIONS:
{'NlcETCertification / r.*Panel Certification
/
.i.proof of Liability Insurance
[z eurouATIC SPRINKLER SYSTEMS - Fire Sprinkler conftactors shall have aminimum "' * "..T#ll Jl,i5tfr$Hi:dFTJf;ib * r,
t NICET Certifi cation - fuc,,t, e €ta'- t e Fr ye- Tle tecl,-,yt t* s a-rrt
* Any Additional Certifi cations
'i.Proof of Liability Insurance
drt*uExrrNGUrsHERS
{.Proof of Certification & Training
E eurouerlc FIRE ExTINGUTsHTNG sysrEMs FoR coMMERcIALCOOKING
*Ptoof of training for commercial cooking heads
E specmr HAZARD sysrEMS
E/nmn PUMPs
-l -
BY:
n STANDPIPE SYSTEMS
SMOKE CONTROL SYSTEMS
g h tr n e @ r".xe'o n* /tre' caw
Amanda Saurey
From:
Sent:
To:
Cc:
Subject:
Amanda,
Nesha Pabst < Nesha.Pabst@doi,idaho.gov>
Monday, May L2,2014 3:10 PM
Amanda Saurey
sha ne@ rockcreekfi re.com
Shane Broderick/Rock Creek Fire Protection
Shane Broderick has full filled the state requvements to obtain aEire Protection Sprinkler Contractor license
in the state of ldaho asrequired in IDAPA 18.01 .49.02.a.Ihave on file thathe took the exan otrJune 15,
2010. State requires either the NICET III or passing the state exam and providing proof that they supervise or
installed atleast (a) fire sprinkler systems of more than 200 hundredheads each.
Please let me know if you need anyfhing else,
Thanks.
%'/" Z/r/
Administrative Assistant
Idaho State Fire Matshal's Office
700 W. State St., 3d Floor
Boise, lD 83720
PH: (208) 334-4370
FX: (208) 334-4375
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***PLEASE PROWDE DOCUMENTATION OF TRAINING LEWLS,
TNSTALLATTON CERTTFTCATTONS, LrABrLrTy rNS UR 4IIC4 ETC. FOR,4LL
DISIPLINES***
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO
REPRESENT:
COMPAI\TY NAME:
COMPANYNAME:
COMPANIYNAME:
COMPANIYNAME:
COMPANYNAME:
COMPANYNAME:
COMPANIYNAME:
COMPANTYNAME:
COMPANTYNAME:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
PHONE #:
I certiS that I have read this application and declare under penalty of periury that the information contained
herein is coffect and complete. I agree to comply with all city ordinances, adopted codes, and state laws
relating to the installation, modification, service, and maintenance of new and existing life safety systems. I
hereby authorize representatives of this city to inspect any work for compliance purposes. I am either the
contractor responsible for the work, or I represent the owner as signified above and am acting with the ownet's
/contractot's frrll knowledge or consent.
Sho* 3.ad.un
PRINT NAME OF APPLICANIT
PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR.
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#ry CERTIFI E OF LIABILITY INSU CE oAIE {il$TDOTYYYY)
2120/2014
THIS CERTIFICATE IS ISSUED AS A IIATTER OF II{FORMATTON ONLY AND CONFERS I{O RIGHTS UPON THE CERNFrcATE HOLOER. THIS
CERTFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AiIEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES
8ELOW. TH|S GERTTFTCATE OF TNSURANCE DOES NOT CONSnTUTE A CONTRACT BETWEEN THE ISSU|NG TNSURER(S), AUTHORTZED
REPRESENTANVE OR PRODUGER, AND TTTE CERTIRCATE HOLDER.
IMPoRTANT: lf the c€rtificate holder is an ADDITIONAL IN$URED, the policy(ies) musl be endorsed. lf SUBROGAION lS WAIVED, subiect to
the terms and conditlons of the policy, certain policies may r€guire an endorsement. A statement on this certiffcate does not conf€r rigms to the
certiftcate holdsr in lieu of such endorsement(s).
PROgUCER
Mutual. Inguranee Assoc., fnc.
1575 Baldy Ave
PocateLLo ID 83201
iXS*i"'Chris Ricbmond
, F,rt. (208)237-9696 | Iff ".u
(2os)2!?-e6e7
ERS!".. chrisr8nutualid. con
INSTJRER{SI AFFORDING COI,ERAGE TAIC I
r,rsuREBA.Seneca SpecialtV Insurance Co.10729
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Roek Ca€ek Fire Proteelion LtC
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American FaIIs ID 83211
rxsuneneAssociated Internationa'l Ins !7189
NsuRERc:Idaho State Insurance Fund t5129
IIISTFERD:
IT{ST'RER E:
INSURERF:
COVERAGES 3-14 REVISTON
THIS tS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED I'IAME' AB6VE FoR THE PoLIcY PERIoDINDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT IO WTIICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICTES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERIi|S.EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
GENEML LIABILIW
crArMs-MADE lTlo""r"
G$TL AGGREGATE UMIT APPUES PER
AUTOtr(PILELI.ABIUTY
ANYAUTO
ALLOWNED f--'ISCHEOUUOAUTOS I-J AIJTOS
HIREDAUTOS I I AUrbE
TyoRXERS COilPENSAITOT|
A!{DEIIPLOYERS'LIABIUTY YrNANY PROPRIETOR'PARTNER'EXECUTIVE T-]OFFICER MEi/AER E(CLUDED? I IlMandatory ln NH)
DESCRIPTIO!{OFOPERATIO|{STLOCATIOIiISTVEHICLES {AritchACORDt0l,AddltlonalRmal€Schedutr,|fmorn6p.calstgqul6{
CERTIFICATE HOLDER CANCELT.ATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFOBE
THE EXPIRATION DATE THEREOF, NOTTCE WILL BE OELIVERED INACCORDANCE WITH THE POLTCY PROVISIONS.
AUTHORIZEO REPRESENTATTI'E
Marks.lcHRIS
ACORD e5 (2010/05)
lNS025 rzoroosrot
@ 198&2010 ACORD CORPORATION. All rigftrts re*rved.
Tha ACOtrfl ntm an.l lona ara raaie?aarl mrrlrc af, Aar.talfl
http://eo2.commpartners.com/usen/nafed/posteventphp?id=9549&se=oPrinable Certificate
National Association of Fire Equipment Distributors
THIS IS TO CERTIFY
SHANE BRODERICKRocK CREEKFTRE ?l?:ll.roN LLc
Has Completed NAFED's
Ponable Ffue Extinguishet Technician Program
Online
January 30r20M
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Date: 0310612014
ReceiPt #: 1367
Rock Creek Fire Protection
Annual Safety Certifi cation
Permit #: 14-00093
Permit Type: rtResAFETy
100.00
Please contact the Building Department at
(208)37 2-2341 f or f u rthe r q u estion s a bout th is
receipt
MAR 0 6 2014
CITY OF REXBUBG
24Hour Notice for inspections
Call inspection hotline at
(2081372-2344
***Credit card payments are accepted, but are subject to a 3% convenience fee on payment amounts over $500***