HomeMy WebLinkAboutAPPLICATION - 06-00228 - BYUI - Fire Safety CertificationZIS
CITY OF
RFXBUR.G
"SAFETY SYSTEM
CERTIFICATION PERMIT"
APPLICATION
"A safe
existing
PERM IT#:
$100 Fee Pal :Yes
o PermitApprovedo Yes/No
BY: Date:
tY system certification permit is required to install, modify, maintain, or service all new and
fire extinguishers, fire suppression systems, fire alarm systems, and other life safety
systems within MtCity of Rexburg "
E3USINESS NAME: Yi • , t,
OFFICE ADDRESS:__
OFFICE PHONE NUMBER:
CONTACT PERSONV/jj1i.,,6CELL PRONE #: _ 313 ��j
Parcel:
PLEASE IDENTIFY SYSTEMS TO BE COVERED BY THIS PERMIT- CHECK ALL THATAPPLy.
_FIRE ALARM SYSTEMS -Alarm Contractors shah have a minimum of NICET Level 1 Certifications
:'PLEASE PROVIDE CERTIFICATIONS:
❖NICET Certification
:*Panel Certification
****Proof of L iability Insurance
_AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minimum of NICET Level III
Certifications,
❖PLEASE PROVIDE CERTIFICATIONS;
****NICET Certification
❖Any Additional Certifications
❖Proof of Liability Insurance
�/FFIRE EXTINGUISHERS
_SPECIAL HAZARD SYSTEMS
STANDPIPE SYSTEMS
_FIRE PUMPS
_SMOKE CONTROL SYSTEMS
_AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING
'PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS, LIABILITYMSURANCE, ETC.
FOR ALL DISIPLINES.***
BUSINESS NAME:
PLEASE LIST ALL COMPANIES YOUR BUSINESS IS AUTHORIZED TO REPRESENT:
COMPANY NAME: PHONE #:
COMPANY NAME:
PHONE #:
COMPANY NAME;
PHONE "***PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS'
ON THE BACK OF THIS FORM****
I certify that r have read this licafion
d declare under penalty Of Perjury that the 'Information � •
l! M +�rdr�ar�, adopted odes, and its laws r�t��r� �rrt�r���' i�r��rr r correct ar�dCo ��
relating �� t� installation, �c��f�ff��#«n� service �� � te. ! aretorr�plwith
herb authorize representatives (this i to , � d' maintenan e o new andexisting
�r���t �r� work to r i�,�iia r� purposes. llife �systems. !
owner signified n tiro a either the contractor responsible for the word
i#� the �r��r' ��+�tr��t�r' full �r� �r ��� � �r I r��r�nt the
'el' _ -
PRINT NAME OF AP LICANT
DATE
9
a
APPL4CANT'S SIGNATURE
PERMIT VALID FOR ONE YEAR FROM DATE
OF APPROVAL.,
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