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HomeMy WebLinkAboutAPPLICATION & CERTIFICATE - 06-00108 - Gem State Fire Protection - Fire Safety Certification19 E. Main St. Rexburg,ldaho 83440 www.re- xbu- r`.o org "SAFETY SYSTEM CERTIFICATION PERMIT" APPLICATION BY: 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 NAME: OFFICE ADDRESS: /2 c OFFICE PHONE NUM..B.-~E-'R: n~D~iS_ ~41-31i3/y CONTACT PERSON: sle [ ~: ~~pf~~ CELL PHONE #: Phone:208-359-3020 x326 Fax:208-359-3024 cdd@rexburg.org PERMIT#: ~ LQ Q $100 Fee Paid: Yes/No Permit Approved: Yes/No -~oRao ~3 yD/ 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 1 Certifications •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. •PLEASE PROVIDE CERTIFICATIONS: •NICET Certification •Any Additional Certifications •Proof of Liability Insurance FIRE EXTINGUISHERS SPECIAL HAZARD SYSTEMS STANDPIPE SYSTEMS AFIRE PUMPS SMOKE CONTROL SYSTEMS AUTOMATIC FIRE EXTINGUISHING SYSTEMS FOR COMMERCIAL COOKING ***PLEASE PROVIDE DOCUMENTATION OF TRAINING LEVELS, INSTALLATION CERTIFICATIONS, L/AB/LITYINSURANCE, ETC. FOR ALL DISIPL/NES.*** I BUSINESS NAME: ~p -rte 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 I have read this application and declare under penalty of perjury that the all city ordinances, adopted codes, and state laws relating to the installation, modi hereby authorize representatives of this city to inspect any work for compliance rp owne~ignified abo and am acting with the owner's /contractor's full kno edge PRINT AME OF APPLICANT APF ~~alo~ xmation contained herein is correct and complete. I agree to comply with ~, service, and maintenance of new and existing life safety systems. i s. I am either the gpntractor responsible for the work, or I represent the consent. /' ~~ N CANT'S' DATE ` PE~IT VALID FOR ONE YEAR FROM DATE ****~***~************~*****~*****************~*~~*****~~***~:~*,~********~11***** ~F*APP*RO~~L*****~~:~***,~,~*~***** .'n ~ .°. o- 7 f ~~~- tt p~ c 3. s,; ~1r t -: 2 t~ l~ ~' € ~r a r v -~ z 0 c z v m 030 m w .~ m N O O -~, : _ f { , 3 . - ~- ,~ n~:-- may..: ~o N~ O O~ ~~ ~..~ M + x~~ o ~' ~' o~ ~~~ ~' ~ ~ rz~ ~ ~ d O "'~ ~ n z~ n m -~ ~n n -~ m -~ -e o~ z~ -o -~ mm ,~ 3 3 -~ ACORDM CERTIFICAI~OF LIABILITY INSURA E o6io jzo 6 PRODUCER (208) 524-5858 FAX (208) 522-8049 Egan, Metcalf & Leavi tt 3780 N. Yellowstone THIS CERTIFICATE IS ISSUED 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 Gem State Fire Prote INSURER A: Rel Mark Program Managers PO Box 2620 INSURER 6: Unigard 025747 Idaho Falls, ID 83403 INSURER C: Idaho State Ins. Fund INSURER D: INSURER E: I:UVtKO(iFti 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 MAYBE 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 DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY D35559978 01/01/2006 01/01/2007 EACH OCCURRENCE $ l 000 ~ 000 ~ )( COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ loo' 00 CLAIMS MADE a OCCUR MED EXP (Any one person) $ 5 ~ ~~0 A PERSONAL & ADV INJURY $ l 000 000 GENERAL AGGREGATE ~ ~ $ 2 00~ ~0 GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS -COMP/OP AGG ~ ~ $ 2 ~ D0o ~ 00 POLICY JECT LOC AU TOMOBILE LIABILITY BA605865 06/01/2006 U6/U1/2007 X COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1 000 000 ALL OWNED AUTOS B , , ODILY INJURY $ B SCHEDULED AUTOS (Per person) X HIRED AUTOS X BODILY INJURY $ NON-OWNED AUTOS (Per accident) P ROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN ~ ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY BE9300294 01/01/2006 01/01/2007 EACH OCCURRENCE $ 1 ~ Q~~ ~ QD OCCUR ^ CLAIMS MADE AGGREGATE $ A 1000000 $ 1,000,00 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 566643 01/01/2006 01/01/2007 WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE ~ E.L. EACH ACCIDENT $ 5Q0 ~ QQ OFFICER AIEMEER EXCLUDED? If yes, describe under E.L. UiSEASE - EA EMPLOYE $ 500 ~ QQQ SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 500 , OQQ OTHER DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS E: Insureds Operations City of Rexburg 19 E. Main Street Rexburg, ID 83440 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL lU 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 INS AUTHORIZED REPRESENTATIVE Jaime Bradley/JB ITS AGENTS OR REPRESENTATIVES. AI.VKU L5 (LVU1/US) ©ACORD CORPORATION 1988 I - ., ,. ° ~a ~ ~ ~ - L ~. _ i 1 .~ ~. -~ ~, I, ~ . - ~ a, .. kz~ ~~' _ .o ~ ~ .~~ CA ~ p _ ti I ~ ~ ~1 ~ ~ a . ~' s . ~ ~ ~ ~ ~~ ~ ~ ~ ~~ .~ : _ ~ .~ ~ ~ ~ ~ ..~ ~ . ~ ~ ~ ro ~ ~ p• ii ~~ r ~ . .. ~ ~ ~ .. ~ ~, ., _.. a ._ . ~. ., _. - ~ ~. P , T~'I Nn~ ~~~_ora~n " ACORD CERTIFIC~'~'E OF LIABILITY INSURA~E OATE(hIMIDD1YWt1 PRODUCER (208) 524-5858 FAX (208) 522-8049 E 02/28/2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATI gan, Metcalf & Leavitt ON ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE 3780 N. Yellowstone HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR PO Box 2498 , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Idaho Falls, ID 83403 INSURERS AFFORDING COVERAGE INSURED Gem State Fire Prote NAIC # _ Ir•J:_,uRER A Rel Mark Program Managers PO Box 2620 Idaho Falls, ID 83403 IIJSLIRERB Unigard 025747 IrJSURER c Idaho State Ins. Fund IIJ:;URER G - - ~ ~ --- IN~URER E --- ---- COVERAGES 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 OT HER DOCUMENT WITH RESPECT TO V'JHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCR IBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCE D BY PAID INSR DO'L CLAIMS. LTR INSRD TYPE OFINSURANCE POLICY NUMBER POLICY EFFECTNE POLICY EXPIRATION --~_-- ~ DATE MfdIDD DATE MMlDD LIMITS X c:01NtvIER~"ItiL GEPJEFU~L L IEILITY rs~crcoo~4 m irn »nnc m im.i~nm care-~-~-,,c~o~e,r~ ~ D,+A•1.4:aE TO RENTED s .aoo, aoo ~ 100 , 000 FERSOIJ~;L k FC~v INJUIY `E 1 , 000, 000 - GE J 61'L AOGREBVTE LIP 41T kPPL E6 PEP GEf~IEF'.aL AGGPEG?SE - g 2 , 000 000 , PRrI- X F'GLIr'r' JECT L?C --- PRODUCTS C~~M1/G;~°IF A,!;G , ~ 2, 000000 AUTOMOBILE LIABILITY BA605865 06/01/2005 06/01/2006 X AtJ`!?JJTU CUWiB RJEC~ ~INCSLE LIIv11T ~, ALL OVYNECi ,4UTi ~S (Ea acc ds-rti ]. , 000, 000 g SCHEDULED ALTOg E'OG L'r' IIUJURY X wRED,au-cs IFer person! X IVON-0\AIPJED AUTOS BOD L r' RJJURY __ __ (F<r accidea; RRGFERT" C!a,lv1?,.~E IFer accidan:; ff GAR AGE LIABILITY r",fJY .PJJTV A,IJTOGNL'i-EAACCIGEM1T g OTFERTHAIV -A. ACC g ALIPJ ONLY' EXC ESSIUMBRELLA LIABILITY ~;~ BE9022035 01/01/2006 01/01/2007 EArH SCCUPREIJ( ~Oi=C.IR ^rLAIh:I~MHGE =E ~ 1,000,000 A kc:cRe~;xTE g oEOUCrIeLE 1000000 t 1,000,000 RETENTIOPd ¢ -_-- -__ g WORKERS COMPENSATION AND EMPLOYERS'LIABILITY 566643 ff 01/01/2006 01/01/200] X TyRr a iT rER APJY ~R IRRIET.-~R/RV,RTNER!EKECLTIVE n ,~+ _ C'FFICE7,T,1EP.48EE E'>`C_UCED? E L EACH HCCIGEPJT $ 500,000 If ',gee, ~9anbe ender SPECI,aL ~R"~VISI:~NS hale~vu E L. DISEa,SE- EH Ev,1FLU`fEE ~ _500, 000 __ OTHER EL GISE?,SE-ROJCY LIP/IT g 500, 000 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEtdENT! SPECIAL PROVISIONS E: Insureds Operations City of Rexburg 12 N. Center Rexburg, ID 83440 ACORD 25 (2001!08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL lO 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 Jaime Bradley/JB ~`~' ~ha ©ACORD CORPORATION 1988