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HomeMy WebLinkAboutAPPLICATION - 18-00713 - 3-D Fire Protection Annual CertificationRexburg -Madison County Emergency Services 35 N Pt E Phone: 208.372.2341 Rexburg, ID 83440 www.rexburg.org Fax: 208.359.3022 C I T Y O 1 REXBURG America's Family Community SAFETY SYSTEM CERTIFICATION PERMIT APPLICATION PERMIT#: $100 Fee Paid: ❑ Yes ❑ No Permit Approved: ❑ Yes ❑ No M Da "A safety ystem cert cation permit is required to install, mod , maintain, or service all new and existing fire extinguishers, fire suppression gstems, fire alarm gstems, and other life safe y gstems with' 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 Parcel: 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 I 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 •:+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 TRAINING LEVELS, INSTALLATION CERTIFICATIONS, LL01LITYINSURANCE, ETC. FOR ALL DISIPLINES*** BUSINESS NAME: 3-D Fire Protection PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: COMPANY NAME: PHONE #: PHONE #: PHONE #: PHONE #: PHONE #: PHONE #: PHONE #: PHONE #: PHONE #: I certify that I have read this application and declare under penalty of perjury that the hi 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 /,n acting with the owner's /contractor's full knowledge or consent. LaMar Hayward PRINT NAME OF APPLICANT APPLI /,� /7• A? S SIGNATURE DATE PERMIT VALID UNTIL DECEMBER 31 OF THE CALENDAR YEAR APPLIED FOR. -2- . »©A \ / ^ � . � # . � ° ` � \ w ' �. � � \ � � � ;} ° « � . < _ - � / � - � \ \ � s � ��. ? # � � m � e 2 � � / - ? w m � <\ \�. , ® � » / � ' � \ � d y. � ■ ~ , � ^ � � « ¥ . ? e - � ? � \.� � : d } :.. = a « ° � : � y �- , z . . \ ? . ?l d� �. : ~�� . � § � J � �° < & ° ©° # . �� f \ % �� � : » » �;/ :.\ > ; ? : s � : � . .. » ■ \� / °« .�: \ \ .� ���. 2� l # �� < � x \ «� :1�: §d . � � y �. e y � » :�, . �� � 2� (� ? d \ ^ � # .? . \� � y � `� � �� . � . \ � < a � ��. � � � Page 1 of 1 ACG?RL7rCERTIFICATE OF LIABILITY INSURANCE D12/12/2018 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 Willis of Minnesota, Inc. c/o 26 Century Blvd CONTACT NAME: PAH/ONE 1-877-945-7378 A/C No: 1-888-467-2378 P.O. Box 305191 E-MAIL ADDRESS: certificates@willis.com Nashville, TN 372305191 USA INSURER(S) AFFORDING COVERAGE NAIL9 INSURERA: Insurance Company of the State of Pennsylv 19429 X COMMERCIAL GENERAL LIABILITY INSURED Delta Fire Systems, Inc. INSURER B: National Union Fire Insurance Company of P 19445 INSURER C: New Hampshire Insurance company 23841 DBA 3-D Fire Protection, Inc. 6312 S Burgraff Way INSURER D: _INSURER E: Idaho Falls, ID 83405 INSURER F: COVERAGES CERTIFICATE NUMBER- W9160018 DGVlclnu WnIUIDCn. 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. Ln TYPE OF INSURANCE ADDLSUBR pOLiCYNUMBER —POLICY EFF MMIDD/YYYY POLICY EXP MWDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY CLAIMS XOCCUR EACH OCCURRENCE $ 2,000,000 DAMAGE TORE ED 1 , 000 , 000 PREMISES Ea occurrence $ -MADE A X Contractual Liability MED EXP (Any one person) $ 10,000 PERSONAL &ADV INJURY $ 2,000,000 GL 746-88-12 12/31/2018 12/31/2019 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4, 000 , ODO POLICY JEHT [:�] LOC PRODUCTS -COMP/OPAGG $ 4,000,000 $ OTHER: AUTOMOBILE LIABILMY COMBINED SINGLE LIMIT Ea accident $ 5,000,000 X BODILY INJURY (Per person) $ ANY AUTO B OWNED SCHEDULED AUTOS ONLY AUTOS CA 657-93-31 12/31/2018 12/31/2019 BODILY INJURY Per accident $ ( ) X HIREDX NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION_ X AND EMPLOYERS' LIABILITY Y / N STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 C ANYPROPRIETOR/PARTNER/EXECUTIVE No N/A OFFICER/MEMBEREXCLUE WC D14-62-9635 12/31/2018 12/31/2019 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) 8 yes, describe under E.L. DISEASE- POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS bebw DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, maybe 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 ANL r_LLA I IVN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Rexburg AUTHORIZED REPRESENTATIVE P.O. Box 280 Rexburg, ID 83440 v 1VUU-2076 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD sR zn: 17201556 BATCH: 985748