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HomeMy WebLinkAboutAPPLICATION, NICET, INSURANCE - 19-00022 - Shilo Automatic Sprinkler IncCITY OF R EXBURG rimerirus Lizmi!}' Corhm��rrit}� Submit By Email Building Safety Department City of Rexburg Safety System Certification permit Application 35 North 1St East Rexburg, Idaho 83440 For 0IlIc:t t'so Permit Number: Permit approved: ❑ Yes ❑ No $100 Fee Paid: ❑ Yes ❑ No 1.111-o rertt-Owner Business Name: Skile Sorink le -e :C;%, - Office Address: IJ.. 4 Its` ACity: Ke.ni►na. State: iU Zip Code: Office Phone:lT_bbbt. Contact Person: _S}avr Seas Cell Phone: (*Lo2j) 4iA- 1,130 2. Proiect Description Please identify systems to be covered by this permit Check all that apply: ❑ Fire Alarm Systems -Alarm Contractors shall have minimum NICET Level 1 Certification or equivalent *The Following Certifications are Required: oNICET Certification oPanel Certification oProof of Liability Insurance. Automatic Sprinkler Systems - Fire Sprinkler Contractors shall have minimum NICET Level III Certification or equivalent •The Following Certifications are Required: oNICET Certification oAnyAdditional Certifications oProof of Liability Insurance ❑Automatic Extinguishing Systems for Commercial Cooking 0 Proof of training for commercial cooking heads Required ❑ Fire Extinguishers • Proof of Certification and Training Reqldr []Standpipe Systems ❑ Fire Pum s ❑ S ecial Hazard Systems ❑ Smoke Control Systems 3. Pt pre- c=Mcd Contpanit s Please list all companies that your business is authorized to represent Company Name: Phone Number: Company Name: _ Phone Number: _ Company Name: _ Phone Number: _ Company Name: Phone Number: _ Company Name: Phone Number: Company Name: _ Phone Number: ***DI EASE PROVIDE DOCUMENTATION nF TRAINING I FVFI_S INSTALLATION CERTIFICATIONS, LIABILITY INSURANCE, ETC, FOR ALL DISCIPLINES*** APPLICANT'S SIGNATURE, CERTIFICATION AND AUTHORIZATION: Under penalty of perjury, l hereby certify that 1 have read this application and state that the information herein is correct and I swear that any information which may hereafter be given by mein hearings before the Planning and Zoning Commission or the City Council for the City of Rexburg shall be truthful and correct. I agree to comply with all City regulations and State laws relating to the subject matter of this application and hereby authonzed representatives of the City to enter upon the above-mentioned property for inspections purposes. NOTE: The building official may revoke a permit on approval issued under the provisions of the 2012 International Code in cases of any false statement or misrepresentation of fact in the application or on the plans on which the permit or approval was based. Permit void if not started within 180 days. Permit void if work stops for 180 days. Applicant's Name (print): Si&h__& 1,S Signature^; -J te: Inspections must be called in before 8 AM on the day the inspection is requested. Inspection requests called in after 8 AM will be scheduled for the next business day. Inspection Hotline - (208) 372.2344 www.rexburg.org Permit Technician - (208) 372.2341 Revised March, 2016 z 0 m > = n n ITI x D Z r cn `C7 z LA © p = n mm z W >°?f Ln 1>1m-- 0 0 c 0 z o c r `00 .� c°. Lon 0 IQ IQ vz �m p m� Qz��� �rn v "I m z Z Mn `" n o o 0T 0n > 10 m zW C d Ln Q m C <r� m _= m 17 ® mn L z n n rn C C) C) m m --A ACOROr CERTIFICATE OF LIABILITY INSURANCE `11%� 1 DATE(MM/DD/YYYY) 9/18/2018 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 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 Mary Thibodeau ISU Cunnington & Associates P.O. SOX 429 LPHF.,xt: (208)672 -6180 NC No: (208)375-8280 E-MAIL mar Qisucunnin ton.com ADDRESS: y g INSURER(S) AFFORDING COVERAGE NAIC R Eagle ID 83616 INSURERA:Nautilus Insurance Co. 17370 INSURED INSURER B:National Union Fire Ins. Co. 19445 Shilo Automatic Sprinkler Inc. INSURERC:Scottsdale Ins Co 41297 1224 11th Ave N INSURERD:Ins. Co. State of Pennsylvania 019429 INSURER E: Nampa ID 83687 INSURER F: COVERAGES CERTIFICATE NUMBER:9-30-18 RFVISION NIIMRFP: 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR EACH OCCURRENCE $ 1,000,000 RENTED 100,000 DAMAGE(Ea occurrence $ PREMISESS MED EXP (Any one person) $ 5, 000 ECP200386717 9/30/2018 9/30/2019 — PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY F JECT F7LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS CA 4489601 4/1/2018 4/1/2019 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 C, EXCESS LIAB CLAIMS -MADE UMS0028266 9/30/2018 9/30/2019 DED I I RETENTION $ 10,000 $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? ❑X (Mandatory in NH) If yes, describe under N / A WC 12016222 4/1/2018 4/1/2019 PEROTH- STATUTE X ER EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1, 000, 000 E.L. DISEASE - POLICY LIMIT $ 1,000, 000 DESCRIPTION OF OPERATIONS below A Professional Liability ECP200386717 9/30/2018 9/30/2019 Per Occurrence 1,000,000 Deductible $5.000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Proof of Coverage (208)287-7129 Ada County Department of Administration 200 W. Front Street Boise, ID 83702 ACORD 25 (2014/01) INS025 (201401) I IVIV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Mary Thibodeau/MARY 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD