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HomeMy WebLinkAboutAPPLICATION & CERTIFICATES - 06-00104 - Omni Security Systems - Fire Safety Certification ~~ ~~'~~~~ CITY Dt- ~' ~~ +~"~` ANtERtCA'S FAP<ttLY COfvtMl.INrrY 19 E. Main St. Phone: 208-359-3020 x326{ `i$~sN'Ea Rexburg, Idaho 83440 Fax: 208-359-3024 www.rexburg.org cdd@rexburg.org "SAFETY SYSTEM PERMIT#: CERTIFICATION PERMIT" $100 Fee Paid: Yes/No Permit Approved: Yes/No APPLICATION gY: Date: "A safety system certification permit is required to install, modify, maintain, or service all new and existing fire extinguishers, fire suppression systems, fire alarm systems, and other life safety systems within the City of Rexburg" BUSINESS ~JAN1E: U~~ ~Jle~ ~% ~C/ld~ ~~'G Parcel: OFFICE ADDRESS: ~~~J?_ ,~/~ ~ ~~/~ ~' "~ ~~~-~~ ~.~ ~-~~~~ OFFICE PHONE NUMBER: ~~ ~ ~~~ /aid CONTACT PERSONri~J,~rr~ CELL PHONE #: ,.~0~ ~~ ~~~,1 PLEA E 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 •PLEASE PROVIDE CERTIFICATIONS: •NICET Certification •Panel Certification -' •Proof of Liability Insurance r i'G~~QGt 6-1'1 a °a1 ~ OY AUTOMATIC SPRINKLER SYSTEMS * Fire Sprinkler Contractors shall have a minimum of NICET Level III Certifications. •PLEASE PROVIDE CERTIFICATIONS: •NICET Certification •Any Aaaitionai Certifications •Proof of Liability Insurance FIRE EXTINGUISHERS STANDPIPE SYSTEMS SMOKE CONTROL SYSTEMS SPECIAL HAZARD SYSTEMS FIRE PUMPS AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING ***PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS, LIABILITY-NSURANCE, ETC. FOR ALL DISIPLINES.*** ~ • BUSINESS NAME: ~i~~/~~~~i'V2%~'~~~jl~~-~S ~i~G PLEASE LIST ALL CO,M~PANIES YOUR BUSINESS IS/AUTHORIZED TO REPRESENT: C,/ COMPANY NAME: /~1~~~i~i~~~i'~/ ,~ PHONE #: ~~~ ~ / ~ ~j~j~ COMPANY NAME: /4'/i~ ~~/d~l~i~/On~~ONE #: .~i~~/%'%~~~ COMPANY NAME: PHONE #: *****PLEASE LIST ADDITIONAL COMPANY AUTHORIZATIONS ON THE BACK OF THIS FORM**** I certify that I have read this application and declare under penalty of perjury that the information contained herein is correct and complete. I agree to compty with all city ordinances, adopted codes, and state laws relating to the installation, modification, service, and maintenance of new and existing life safety systems. I hereby authorize representatives ofthis city to inspect any work for compliance purposes. I am either the contractor responsible for the work, or I represent the owner as signified above and am acting with the owner's (contractor's full knowledge or consent. ~~~ ~~~~c PRINT NAME OF APPLICANT PLIGANT'S SIGNATURE - ~ ~-~~ DATE PERMIT VALID FOR ONE YEAR FROM DATE OF APPROVAL. ~~**********,~***~*******~**********,~***************~**~*~**:~*,~*~:~*******~*****~***,~***~**,~*~,~;t**,~*,~,~,~******** y~ T ~~~LS~ ~ ~#~~~ ~~~ ~ x ~~ a ~ '' ,~- .~~~ ~.,. ~. Z m a _r d -~ 0 c v m ono m o~ wa "'" m O N O O ~o- N~ O O O M..~ 0 O ~I z ~ ~ ~ ~' ~ 00 ~ ~ ~ ~ ,~, ~ ~" ~ ,~ W O U~ Z ~..r z n n m -~ n -~ Y m -~ -e o ~' z ~' -o -~ mm ~3 3 -~ • • Pere~eee~lr I uAe e~a~l~r~e~ee~/ri~~~rpweMleer~eaw~~e~w~e~ ~. _~~•. ~.:'ds n.~a;;`g3w''k'~f'+s?F`:yvgepi:., .. .;.~,,,,~, ..:.!r.: Yi:S:;.dt,. •{€'.. '~+. v w x ;~ 0 z r 0 0 ~o 0 m a z r r~ z n z n ~~ ~ y b d r-~ S ~ ~ ~~~ ~ ~ ~ ~ ~ ~ r-r o ~ ~~~ y O y ~ m ~ ~. n ~ ~ ~ ~ ^' ~- o y~y ~' ~ ~ ~~Q ~~~ ~ ~ ~ '.~ „.+ a ~' t~ G~ ,~'' ~~n ~ ~~~ n ~ '~ O ~' ~ Z ~ ~ ~ Gbh ri n ~ Y ~ m ~ ~ ~ ~., ~ ~ ~ k t"" ~ p ~ ~~!! y O C G P- ~' C ^ ~ .~., ~ ~ ~ ~ ~ K ~ n ~ o n ., ~~ ~~ ~~ ~o ~~ ~~ ~~ ~~ ti ~z ~~ ©~ ~Oz r~ ~. ti N r n y n r r^~ 1 L y O 3 s E g ~~ ~~ R V~~ ~~ i ~64 s~3 ~e~ p ~~ • r r~ y O d y C~7 I O i ~ ~~ ~ ~O C~J I ~ O ~_ ~~ w ~I,Il,al,~ II ,,,,. ,.,,~.,,, ,,~,.,,III,I~,..„aal,,,.a~. ,,,,I~,ILII~I,,,,,,.Y,III,..L .............„,IM,,.Im,..l,, II„..,a„~I,.,,~.m..,,..,~,,.~,,..,,~•..,,.,.,,,,...,,,,,,,,.,,.~............, n ._-M, _ _ ~ -- ~°* ~ 1 ~ ~ o ~~ ~ Q- ~ ~ ~~ ~ ~ ~ ~ ~: ~ . _ _ O ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ f ~ ~ ~ , - ~., M ~ N i.r. 0 _.. ,.~ i ~ ~ ~ ~. - ~~ ~ ~~ ~ ~ ~ ~• ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ n `y 0 ~ • ~ Cn0 ~ ~~ ~ y ~ ~ ~ ~ ~ ~ ~"~ ~ y O ~~~,• ~ 3 o ~ ~~ rp ~~ ~ O N ~ ~ Mrt~ vs ~" ~ ~ _ ~ ~ y N ~ ~ 4, ~ C ~ ~ ~ ~ ~ __ r ~ , ,.~ ~ ~ ~ o ~~ o ~ ~ ° ~ ~q o ~ n ~ ,~, o ~ N E. E:- i~ _ 3 aWILLU'uu ~I wuww ulu.lu ~1 Iwwul u.w. ullwllw lluwul WI •.~~I.ul . II UIIII ~ILI Wut.l a u~~II IIIU I:IIUJI.wwlullu111WYU11Wliw~llllullw 1 I ululwwowwuuuuwwuwl. •JWwIwuWWwuwiu 3 ~l IW N' ~' l ~l :,;~- „,_ 4~ I m' 8 y c~ ~n c ~z ,~, ~ ~ ~~~ ~'~ ~• ~~ I a m ~® a ° ~~ ~ ~~, ~ ~\ c~ ~~~ ~~ ~, a C° c~ ~ a ro 0 0 S 0 0 ~C H 0 la ro 0 0 ~~ ~~ ~' N ~~ g ~~ ~. K r n ~~ c~ t2+ 0 C~ O ~' ~~ O 0 ~~, A ,~ ~., n m c~ n m 0 a n 0 -~ a z z A CORD TM CERTIFICA OF LIABIL ~ ITY INSURA E DATE (MMlDD/VYY1~ 02/27/2006 ~RODUCER (208) 524-5858 FAX ( ) 522-8049 Egan , Metcalf & Leavitt 3780 N. Yellowstone THIS CERTIFICATE IS UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 2498 Idaho Falls, ID 83403 INSURERS AFFORDING COVERAGE NAIC # INSURED Mark Pettichord DBA Omni Security INSURER A. SCOttSdale InS Co 1249 W 7200 S INSURER e: Progressive Rexburg, ID 83440 INSURER c Idaho State Ins. Fund INSURER D: INSURER E. rrniroer_~e 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 CONTRACTOR 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LT DD'L NSR TVpE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MIDD POLICY EXPIRATION DATE MMIDD LIMITS GENERAL LIABILITY CLS0909432 04/26/2005 04/26/2006 EACH OCCURRENCE $ l ~~~ ~ ~~ X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ loo ~ 000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5 , 000 A PERSONAL & ADV INJURY $ 1 , 000, 000 GENERAL AGGREGATE $ 2 ooo 00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO PRODUCTS -COMP/OP AGG , , $ 2 ,ooo , ooo POLICY LOC JECT AUT OMOBILE LIABILITY 08479032-0 03/11/2005 03/11/2006 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 500 DO ALL OWNED AUTOS BODILY INJURY , B X SCHEDULED AUTOS (Per person) $ __ HIRED AUTOS - BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY AGG $ EXCESSlUMBRELLALlABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY 576981 04/01/2005 04/01/2006 X ORYLATU- OER C ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? If yes describe under E.L. DISEASE- EA EMPLOYEE $ 1D0, 000 , SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $ 500, QQo OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS E: Insureds operations City of Rexburg 12 N. Center Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1D DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE j~ JiG' C~ Jaime Bradley/JB /y~'"'_~--L-' j~ ACORD 25 (2001/08) rAx: ~1us)j 5y-jut4 ©ACORD CORPORATION 1988 OMNI SECURITY SYSTEMS, INC. 4134 EAST 200 NORTH RIGBY, ID 83442 208-745- 1020 February 23, 2006 CITY OF REXBURG I AM PROVIDING YOU VE'IT'H MY CERTIFICATIONS AND LICENSE NUMBERS. STATE OF IDAHO ELECTRICAL JOURNEYMAN LICENSE J-12167 STATE OF IDAHO ELECTRICAL CONTRACTOR LICENSE C-15009 STATE OF WYOMING ELECTRICAL JOURNEYMAN LICENSE J-5306 STATE OF WYOMING LOW VOLTAGE CONTRACTOR LICENSE LV-G-159 STATE OF WASHINGTON ELECTRICAL JOURNEYMAN LICENSE ELO1 PETTIML 101 BZ LB.E.W JOURNEYMAN ELECTRICIAN LU 449 CARD # D722010 ICBO CERTIFIED ELECTRICAL INSPECTOR # 1100028-20 NICET LEVEL 2 FIRE ALARM #113099 WE LOOK FORWARD TO WORKING WITH YOU LET ME KNOW IF YOU HAVE ANY QUESTIONS FOR US. Sincerely, _~-- ~ ,. MARK PETTICHORD OWNER OMNI SECURITY SYSTEMS, INC. MAR-O1-2006 WED 03:37 PM ID STATE INSURANCE FUND FAX N0, 2083343254 P, O1/O1 (;h:RTlI+ICATF. fiOI.A1CIt: C:LTY OF ' R)~/XBURG 12 N CENTLIZ RFX!"3UIZG :7.D 8340 ,, STt~T~ INSUItANCF FUND 1215 W. S'I'A'I'1; STRF.I:'C • P.c).130}C 83720 • BOISE, IDAHO 83720-0044 YI-IONL (208) 332-21UU • (SOU} 334-2370 W W W.IT:)AHOSIF.O'LZCr AGN:Nf: 389 EGAN, METCALF >?0 BOX 2498 IDAHO FALLS ZD (208) 524-5858 CCRTTt''IC'A7'f+. Or WORKF~T2S CUMI'CNSATIOIV INSURANCE:, t"u LFAVITT 83403 'Chc; Stan lnsurance Fund hereby cer'til~ies that the insurance policy hereunder described is in full force txnd effect can the d;,1l.e of this certiticat~ and tha[ it rcrpains in full force attd effect until cancelled. 1`UI.T('X' Nt~Mi9L:R: 57G98I OMNI SEC:I1ltITY SYS7"1'-,MS INC ~l 4~ L 34 I :200 N ItT(:a13~" ID ti344?-5818 ()k1CriNAL'.> i:F1~LCTiVL; UA'I'~;: June 1, 200 L T10L[NSON trwusR Rrv. 5/?1700 (I Policy iu Force from June: 1, 20U l I2:0 L a.m. at the mailing address of the insured shown abr.>ve ur the jc~b xi[u in lilt-ho. Pnit'l' TWO: IsMPL~YFrs Llniill~ITY 1NSU12nNCE LIMITS 13udily Injury by Aci;ider-t $100,000 each accident I3ndily Injury by T)iecase $500,000 policy Limit Beefily Injury by J)iease ,$100,000 each employee Thr, insurance coverage applies to employ~cs of the above-mentioned company nttywhere in the state of Idaho and also tc~ any employees livin~± in Idaho but wirrkinfi ternportnily in a neighboring state. In addition tc) the required ecwcruge, the fallowing elecac:d coverage alsc[ iipplles: 'C'hic c~rtificatc it valid for one year 1`ram date of certificate. Xn the event of clncellation of said policy, the State lnnuraneC fund will endelvar te;r notify the party [o whom this certificate is istiuc;d by providing thirty (30) days advanc;c notice, but the State trisurancc rand ~holl nol be Liable in any way L'c,r failure to give notice. T);itcd ar T3nisc., Tdaha un Tvi;trc:h 1, 2UOG. Carc,l 1'rcuyman T.Tndcrwriter