HomeMy WebLinkAboutALL DOCS - 12-00101 - Phoenix Fire Protection Annual Safety Certificationoo
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35N ldE
Rexburg, D 8U4O
Rexburg -Modison Cou nty
Emergency SeMces
Phone: 208.372,2326
Fox:208.359.3022www.rexburg.org
c|f Y ol'
REXBURG
c\' --
Am e ri ca\ krmily Cammuni ty
*A lortA gshn nrtfrdion pemit is nquircd to in$all, modifi, maintain, or smice all new and existiagfn
extingtisbcrs,fn snppnssion gstems,fn alamt yshms, and othr ffe safery gsnns pithin tln Ci\ oJRexbnry"
BUSINESSNAME: PhoenixFirePtotection-Parcet-
OFFICE ADDRESS: PO Box24:2 Victot,ID 83455
OFFICE PHONE NUMBERI -208-468-9115
CONTACT PERSON: -Rochelle Chatles- CEII PHONE #: 308-313'rf%
PLEASE IDENTIFY SYSTEMS TO BE COVERED BYTHIS PERMIT. CHECKALL
THAT APPLY.
FIRE AI-ARM SYSTEMS - Alarrn Conftactors shall have a mioimurn of NICET Level 1
Certifications or equivalent
*PLEASE PROVIDE CERTIFICATIONS:
{.NICET Cetification
t?.Panel Certification
t Proof of Liability Insurance
.:.NICET Level II requited fot design wotk
_X-AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinklet Contractors shall have a
minimum of NICET Level I Certifications or equivalent.
{. PLEASE PROVIDE CERTIFICATIONS :
.:.NICET Certification
{'Any Additional Certifications
{.Proof of Liabiliry Insurance
t NICET Level II required for design work
-FIRE EKTINGUISHERS
*Proof of Certification & Training
-AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL
COOKING
{.Prcof of ttaining fot corrmercid cooking heads
-STANDPIPE SYSTEMS -SPECIAL }IAZARD SYSTEMS
SMOKE CONTROL SYSTEMS -FIRE PUMP
{C{CT'PLEASE PROWDE DOCAMENTATIAN OF TRAINING LEVELS,
INSTALIJITION CERTIFIAffIONE LIABILITT INSURANCE, ETC. FOR ALL
DISIPLINES*#
I cettify that I have read this application and declare undet penalty of petiuty that the infotmation contained
hereia is corect and complete. I agree to comp$ with all city ordinances, adopted codee, and stete lews
relating to the installation, modification, service, and maintenance of new "116 s$slng life safety systeme. I
hetcby authodze rcplcscntatives of thie city to inspect any wotk fot compliance purposes. I am either the
conttactor tesponeible fot the wotlg ot f teptesent the owner as signified above and am acting with the owncde
/contactot's frrll knowledge or consent
_Rochelle Chades_
PRINT NAME OT EPPI,TETq:r
+lt*{r z
DATE
PERMIT VALID I]NTIL DECEMBER 31OF THE CALENDARYEAR APPLIED FOR.
*******{..l..lqlolcirlel.****ffi {st6t
-2-
o PHOFOOl OP ID: GT
,ACORD"
\-/CERTIFICATE OF LIABILITY INSURANGE DATE IIilJDD'YYYV'
10t15'12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORISATIOI.I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTTFICATE DOES IIOT AFFIRTATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERnFTCATE OF INSURANCE DOES NOT CONSTITUTE A COI{TRACT BETWEEN THE lSSUll{G INSURER(SI, AUTHORIZED
REPRESENTATIVE OR PRODUCER, ANO THE CERTIFICATE HOLDER.
ielpdRnXf: |f the certlficate holder is an ADDITIONAL INSURED, the policy(ies) mrct b€ endoned. !f SUBROGATION lS WAIVED, subfect to
the terms and condltions of tho pollcy. cortah policies may require an endorremenl. A statement on this certlllcate does not confer righb to the
certlficate holdor In lleu of such endors€mBnt{sl.
PRoDUCER 208.{,56-2652
{enry lnsuranqe Agoncy
t04 12th Ave. So.
{ampa, lD 83651lobert L. H6nry
c{mrAcrfllxE:
lJ3-*6..''', I li6. nor,
E.I'AIL
ADMFSS:
INSURERISI AFFOROING COVERAGE NAIC *
rirsuRER A : Thg charter oak Flre Ins co
rNsuREo Phoenix Fire Protection, LLC
4{30 Airport Rd.
Nampa, lD 83687
NsuREn s : Travelers lndemnitv co of cT
NsunER c I Travelerc Property & Casualty
rNsuRER D: Co of America
INSURER E :
ll'lSllRFE F I
IIIUMBER:
TTNS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BETOW HAVE EEEN TSSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INoICATED. NoTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF AT.IY CONTRACT OR OTH€R DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, T}IE INSURANCE AFFORDED BY THE POLIC]ES DESCR]BED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCTUSIONS AND CONDITIONS OF SUCH POI-ICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CI.AIMS.
X I colarrrencrlr- GENERAL LrABrLlry
crArMs-MADE [Tl o..u*
GEiTL AGGREGATE LIMIT AFPLIES PER:
AUTOT'OBILE LIABILITY
ANY AUTO
ALt OI,VN€D [*] SCneOUleO
AUTOS | | AUTOSI I NONOWNEDHIREDAUTOS I I AUTos
BoDtLY INJi RY (P;r person)
BODILY INJURY (P6f accidont)
OCCUR
CLAIIlTg.MADE
v\toRl(ER8 COilPEllSAnOil
AilD EMPLOYERS'LIAS|UTY YrilANY PROPRTETOR'PARTNER'EXECL'TVE T----1oFFrcERnrEMEER EXCLUDED? I I
lutrdrtory ln NH!
DESCR|PT|ON OF OPERAnONS ' LOCAnONS ' VEHICLES lAnrch ACORO t0l, ^ddltonrl R.mr.tr scho(tu|o, ll mor. tprc! b rcqdE.l,
CITYORI
City of Rexburg
35NlstE
Rexburg, lD 83440
SHOULD A}IY OF THE ABOVE DESCR|aED POLIGIES 8E CAIICELL€O SEFORE
THE EXPIRATION DAIE THER€OF, NONCE WLL AE DELIVERED IN
ACCOROAXCE WITH THE POLICY PROVISIOHS.
ffffit.f.iiT"1T*-fi4,u J
@ 1988-2010 ACORD CORPORATION. Atl
ACORD 25 (20r0105)The ACORD narna arid logo aro regicbred marks of AGORD
OP lD: GT.-
ACORD"
\-"e/'CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A ilATTER OF IIIFORUANOil ONLY AND CO}IFERS }IO RIGHTS UFON THE CERTIFICATE HOLI'ER TTIIS
CERTTFIGATE DOES NOT AFFIRITAIWELY OR IIEGANVELY AIIEND, P(TEND OR ALTER Tt|E COVERAGE AFFORDED BY TT{E POLICIES
BELOW. TH|S CERTTFTCATE OF TNSURANCE DOES HOT CONSnTTE A CONTRACT BETWEEN THE ISSUTNG INSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND TI{E CERNFrcATE HOLDER.
IMPORTANT: lf the certlflcate holdsr is an IiSIURED, tt€ poficy{ies} muet be ondors€d. It SUBROGAnON ls WAIVEO, subj€ct to
the terms and condlttons of the potlcy, certaln pollcies may requinB an endonsdnent A Etatement on this certiffcate does not confur righF to the
holderin lieu of such
tNsuRED Phoenix Fire Protection, LLC
4130 Airport Rd.
Nampa, lD 83687
,Thg charterOak FIre lns Co
THIS tS YO CERNFY THAT THE POTICIES OF INSURANCE LISTED BELOW FIAVE BEEN ISSUEO TO THE INSURED NAMED ASOVE FOR THE POLICY PERIOO
INDICATED. NOTWTHSTANDING ANY REOUIREMENT, TERTT OR CONDITION OF ANY CONTRACT OR OI}IER DOCUMEI'IT WTTH RESPECT TO WHICH THIS
C€RTIFICATE il[AY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU&'ECT TO ALL THE TERMS.
EXCLUSIONS AND GONDITIONS OF SUCH POUCIES. LIMITS SHOWI{ I'AY }I.A\/E BEEN REOUCEO BY PAID CIAIMS.
TYPEOf II|||URAI|CE tuttB FoIICY IIUIAER uilfi
A
GETTERAL LTABIUTY
X I co$,tsRctAt GENERAL LIABLrY*-l^-].^^*oo.
lTl o""r*
X IXCU lncludsd
DT CO 5292M755 08r07rt{auo7t12
EACH OCCURRENCE s 1,000,00(
UAITICIJe l{J KbNltU
PREtllSES aEr @|mel $300,00(
[tEO EXP {&ryorlo person)s 5,00(
P€RSONAI & AOV INJURY s 1,000,00(
GENER^L AGGREGA1E $2,000,001
GelfL AGGFEGATE LIMTAPPLIES PER:
"o.,""1T1ff$ l--.l.*
PRODUCTS . COilP/@ AGG s 2,000,0(}|
$
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OTOB|LE LTABRjTY
AI{YAUTO
Ar-! owNEoAuTos
$CHEOULEOAUTOS
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COMEIS€D SINGL€ LIMTT(Eaffitdc.rD s I,O0O,O0(
SODILY lLJt RY {Par p€rson)s
EODILY INJURY (Per oodden0 s
PROPERTY DAT'AGE(P6eidnl)s
s
s
c
lrr6RELlr uAa fXl occun
EXCESSUAa I lcr-rnrSrrrnoe cuP 5292ir755 08r07fi1 ou07t12
EACHOCCUFRENCE I 3,(Xt0,0g
X AGGREG^?E s
OEDUCTIELE
RFTFNTT.IN s 10.000
$
x I
AITD EITPLOVERS U^SUTY
Al.lY HOFFFEnnrgrrasEn EXCLUDEO?{Hsd.lory ln ll}l)
N'A
Ih;srAru.I l(,rh.ITNPYITMINI I FP
E^1. EACHACCIDEII'T s
F I NSFASF. FA ilOI OWg s
Ft ntsasg_mreYl 3
D$CnPnON OF OPERATOilS ' LOCArrOilg ' VEHCLES Ottrah ACORO 1Ol. Adrnbn l Rcilrlr Schc(hrlq It '|t@ 3pr6 l| ruqukrdl
crwoRl
Glty of Rexburg
3SNlstE
Rexburg, lD 8344{l
SHOI'LD AHY OF THE ABOVE DESCRIBED FOUCIEE BE CANCELL€O BEFORE
THE EXPIRATIOII DATE TI{EREOF, l'lOTlCE }tlLL BE O€UVEREO rilACCORDANCE WIT}I TI{E POLICY PROVISIONS.
RobertL' HenrY
!A-, { . 1Je*rt*l-"*
@ ACORD CORPORATK'II. AII
ACORD 25 {2009109}The ACORD name and logo are regiotered marks of ACORD
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,evelopment Receipt Number: iQiQ1l&1 'l '
CIT1 I]F RTXFUftG
PAIIT BY: FH0ENI){ FIRI Fft0TtCTI0t{ LLC
itATE: 0lltt/11
TIt{t:1T:11:il
HE lCI31ti cilTR
EtltIF'T tlil: I4B06u
RtF ll0: i55[fi
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10tr,00
finn
D. 83440
208) 359-3022
,us Paymenl
Sdqlnal Fee
Arltount? 8T, FIRT FTR|.IIT ilHNTft :
[Hff]i Ail0uNT
PAYI.lEHT
LT'HNUL
F'ERtlIT $ 1:t]0101
THA}I}i YI]U AIII| HAVI A I.IIIE NA}
$100.00
Total:
$100.00
PAI
MAR r 2 2012
CITY OF REXBURG
$100.00
$ 100.00