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Home My WebLink AboutAPPLICATION - 17-00778 - 3D Fire Protection Safety CertificationRexburg -Madison County Emergency Services 35 N 1s1 E Phone: 208.372.2341 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3022 C I T Y O P REXB RG America's Family Com zunity SAFETY SYSTEM CERTIFICATION PERMIT APPLICATION PERMIT#: $100 Fee Paid: ❑ Yes ❑ No Permit Approved: ❑ Yes ❑ No Date: "A safety ystem certification permit is required to install, modify, maintain, or service all new and existing fire extinguishers, fire suppression systems, fire alarm ystems, and other life safety systems within the City of Rexburg" BUSINESS NAME: 3-D Fire Protection OFFICE ADDRESS: PO Box 50845 Idaho Falls, ID 83405 OFFICE PHONE NUMBER: (208) 525-8377 CONTACT PERSON: Karrie Jones arcel: CELL PHONE #: PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THAT APPLY. ❑ FIRE ALARM SYSTEMS - Alarm Contractors shall have a minimum of NICET Level 1 Certifications or equivalent. ❖PLEASE PROVIDE CERTIFICATIONS: ❖NICET Certification ❖Panel Certification ❖Proof of Liability Insurance ❑✓ AUTOMATIC SPRINKLER SYSTEMS - Fire Sprinkler Contractors shall have a minimum of NICET Level III Certifications or equivalent. ❖PLEASE PROVIDE CERTIFICATIONS: ❖NICET Certification ❖Any Additional Certifications *:'Proof of Liability Insurance ❑ FIRE EXTINGUISHERS V* Proof of Certification & Training ❑ AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING ':'Proof of training for commercial cooking heads ❑✓ STANDPIPE SYSTEMS ❑✓ SPECIAL HAZARD SYSTEMS ❑ SMOKE CONTROL SYSTEMS ❑✓ FIRE PUMPS ***PLEASE PROVIDE DOCUMENTATION OF TRAININGLEVELS, INSTALLATION CERTIFICATIONS, LIABILITYINSURANCE, ETC. FOR ALL DISIPLINES*** BUSINESS NAME: 3-D Fire Protection PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: COMPANY NAME: PHONE #: I certify that I have read this application and declare under penalty of perjury that the in rmation contained herein is correct and complete. I agree to comply with all city ordinances, adopted cod , and state laws relating to the installation, modification, service, and maintenance of new and existin 'fe safety systems. I hereby authorize representatives of this city to inspect any work for compliance pu ses. I am either the contractor responsible for the work, or I represent the owner as signified above a m acting with the owner's /contractor's full knowledge or consent. LaMar Hayward PRINT NAME OF APPLICANT APPLIC T'S SIGNATURE DATE PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR. Credit Card Payment Form: From: 3-D Fire Protection PO Box 50845 Idaho Falls, ID 83405 Amount: $ 100.00 ZVisa 1-1 MasterCard FlAmerican Express ❑ Discover Name on Credit Card: 3-D Fire Protection Credit Card Number: 4808 0170 1292 5939 Expiration Date: 11 / 18 Verification Code: 680 Billing Zip -Code: 84126 Fax or Email Receipt: ❑ Yes F-1 No Email: karrie.jones❑u,3dfire.us Please process this credit card and email receipt to the email listed above. Please call Karrie if you have any questions 525-8377. Thank you a z c m ^ M r - (. CL td >Z >� o Q C tTj Z z 4 o v,in 41 c -. m r r� rn n -►, t/� cn m Cil 1 = c > z ow m a a z `' c� 0 LA to .70 �0 0 m 0 p r m av m mm wl m T z A " CERTIFICATE OF LIABILITY INSURANCE ILTR NSR page 1 of 1FATE 11, 0 17) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis of Minnesota, Inc. c/o 26 Century Blvd. P. O. Box 305191 Nashville, TN 37230-5191 A PHONE 877-945-7378 FAX 888-467-2378 E-MAIL ADDRESS certificates@willis.com INSURER(S)AFFORDING COVERAGE NAIC# GL 746-87-65 INSURERA:Insurance Company of the State of Pennsyl 19429-001 - _ INSURED Delta Fire Systems, Inc. INSURERB:National Union Fire Insurance Company 19445-001 DBA 3-D Fire Protection, Inc. INSURERC:New Hampshire Insurance Company 23841-001 INSURER D: 6312 S Burgraff Way Idaho Falls, ID 83405 INSURER E: INSURER F: B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOSONLY ---' - - RCvlofvrq NUIVIbLK: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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. ILTR NSR TYPE OF INSURANCE DDL _SU B WVn POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X Contractual Liability GL 746-87-65 12/31/2017 12/31/201 EACH OCCURRENCE $ 2,000,000 PREMISEJFENcurence) $ 11090 000 MED EXP (Any one person) $ 10 000 - PERSONAL&ADV INJURY $ 2, 000, 0.00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F �E� LOC OTHER: GENERALAGGREGATE $ 4,000,000 PRODUCTS-COMP/OPAGG $ 4,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOSONLY CA 428-80-74 12/31/201712/31/201 COaaBIINEDSINGLELIMIT $ 5,000,000 X BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ X PROPERTYDAMAGE (Per accident) $ UMBRELLALIAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVErN] OFFICER/MEMBER EXCLUDED? Me ,descnb u ) fyes,dto be under DESCRIPTION OF OPERATIONS below N/A WC 014-62-9548 12/31/201712/31/201 X PER OTH- __ --- E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE EA EMPLOYEE $ 11 000, 000 E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Stop Gap Employers Liability for the Monopolistic States of North Dakota, Ohio, Washington and Wyoming is provided under Workers' Compensation policy, however, Statutory coverage for the Monopolistic states is not. "'L;R GANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. C' i AUTHORIZED REPRESENTATIVE t-., � f o c.,h...-..