agenda amended fire board of appeals
TRANSCRIPT
FIRE BOARD OF APPEALS Amended AGENDA
CC)LORAD() MEETING DATE: November 9, 2017SPRGS
TIME: 8:30 A.M.LOCATION: Fire Department Complex
375 Printers Parkway — Administration Conference Room
CALL TO ORDER
ADMINISTRATIVE
7. Review of Previous Meeting’s MinutesFire Board of Appeals Meeting Minutes — October 13, 2017
2. Contractor Licensing
A. Fire Suppression Contractor (FSC) A
i. Name of Company: Rapid Fire Protection, Inc.Principal Officers: Matthew Hammon, President
Rod DiBona, Vice PresidentBrent M. Zimiga, Treasurer
Applicant: Brent M. ZimigaRME: Brent M. Zimiga
B. Fire Alarm Contractor (FAC) A
i. Name of Company: Complex Technologies LLCPrincipal Officers: Johnathon Mattingly, Operations Manager
Philip Davis, Operations ManagerApplicant: Timothy E. AnthonyRME: Timothy E. Anthony
DISCUSSION
1. Proposed Amendments to 2015’s Edition of the International Fire Code
ADJOURN
Respectfully submitted,
Kris Cooper, Deputy Fire MarshalSecretary to Fire Board of Appeals
Page 1
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I 1*f 1iII’J’)Ii1LI4’’T’Fire Suppression Contractor License Application
(RBD USE NLY
Date t,..f’7 IiIt is requested that the Fire Board of Appeals of the Colorado Springs Fire Department Initial 31consider this appticotion for the state license in compliance with the Pikes Peak Regional j Receip L5- ‘jBuilding Code.
I jFIRE SUPPRESSION CONTRACTOR LICENSE REQUESTED (Check one)
2 FSC-A El FSC-B El FSC-C El FSC-D El FSC-H El FSC-M
Type of Entity (Check one) El Individuat El Partnership 2 Corporation El LLC
Business Name: Rapid Fire Protection, Inc.(The business name is the name that wilt appear on the license and is the actual name under which the contracting business wilt operate.)
Federal Employer Identification Number: 46-0428403
Business Address: 1 530 Samco RoadStreet Address Apartment/Unit #
Rapid City SD 57702City State ZIP Code
Business Phone: 6053482342 Business Email: [email protected]
Business Fax: 6053480108 Business Website: www.rapidfireinc.com
Company s Principat Officers, Partners, or Owners
Name: Matthew Hammon Title: PresidentName: Rod DiBona Title: Vice PresidentName: Brent Zimiga Title: Treasurer1. Number of years the company has operated as a contractor? (If new, write “new”) 23
2. What is the company s area of specialties? Fire Suppression
Type of work performed? (Check one or both, if applicable) 2 Residential 2 Commerciat
3. Has the company ever been named in or responsible for any entered and unsatisfied judgments, tiens,and/or ctaims against them in which the company was the contractor? El Yes No If yes, Explain
4. Has the company been a defendant in a colLection action court case? El Yes No If yes, Explain
5. Has the company ever declared bankruptcy? El Yes 2 No If yes, Exptain
6. Has the company ever had a license suspended or revoked? El Yes 2 No If yes, Explain
7. Has the company ever defaulted on a contract? El Yes 2 No If yes, Exptain
2
1. Project Street Address: see attached
Type of work (check one) 0 Residentiat OCommerciat
Cost:
_______________
Date:
_______________
Your position:
Describe Job in detail:
_____________________________________
2. Project Street Address:
_______________________________
Type of work (check one) 0 Residential ECommercial
Cost:
________________
Date:
_______________
Your position:
Describe Job in detail:
___________________________________
3. Project Street Address:
______________________________
Type of work (check one) 0 Residentiat ECommerciat
Cost:
________________
Date:
________________
Your position:
Describe Job in detail:
___________________________________
4. Project Street Address:
_______________________________
Type of work (check one) 0 Residential ECommercial
Cost:
________________
Date:
________________
Your position:
Describe Job in detaiL:
___________________________________
5. Project Street Address:
_________________________________
Type of work (check one) 0 Residential ECommerciat
Cost:
________________
Date:
_______________
Your position:
Describe Job in detail:
_________________________________
CERTIFICATION (The following declaration is to be signed by the principal officer of the company) The undersigned, onbehalf of the company, partnership or corporation, does hereby declare and warrant that the “examinee” for acontractor’s license named herein has the express authority to bind the company, partnership, or corporation by thisapplication; and further, the company does hereby agree to abide by the ordinances and regulations promulgated by theCity of Colorado Springs, El Paso County, and those adopted by the municipal entities within El Paso County in regard toany work which may be performed by our company pursuant to the contractor license for which this application ismade.
Print Name and title (owner, principal or manager) Matthew Hammon
Signature: Date:
_________
LicenseeInforiiiation:.::.
Legal. Name:La
Date of Birth: OZ)r)5) i—i
Address: I2M ftornae Huivt
i1-First M.J.
Social Security Number: 503 1 53 -2—
Phone: (pD L3- Z.3-2 Fax: (OOiO Emait: rtC. 1t
1. What is your area of expertise in the industry? re. S’(fl
2. How long have you worked in the industry? ‘C) ‘-ear..S
3. What is your affiliation with the company? (Owner, partner, empLoyee, etc.) Frr lJ4Cf
4. Have you ever been convicted of a misdemeanor or felony? LI Yes If yes, Explain
5. Have you had a license suspended or revoked? LI Yesfyes, Explain
6. The examinee understands that direct supervision and control includes any one or a combination of thefollowing activities: supervising, managing construction activities by making technical. and administrativedecisions, checking jobs for proper workmanship, or direct supervision on job sites. Will, you, as thequatifying individuat, perform one or more of these duties? LI Yes LI No
Cecations ...: .......
‘,.;.
NICET # NICET LeveL ExpiresI IO8’tpZ-9
P.E. # Issued E*piresgL1p I t7_.J2,t/I’7D.O.T. # Issued Exires
I I
Company Position To From
- -‘C’h1
CERTIFICATION (The fotlowing declaration is to be signed by the Licensee) Pikes Peak Regional BuitdingDepartment requires aLt persons seeking a license to undergo a Criminal Background Check. I herebyauthorize Pikes Peak Regional BuiLding Department to perform a Criminal. Background Check utilizinginformation provided on this application. I agree and understand Pikes Peak Regional. Building Departmentmay deny me a license after reviewing my Criminal Background Check. If any information provided on thisapplication is untrue, License granted to me is automaticalLy revoked.
Print name & titLe (Licensee): rec
Signature of (Licensee):
Street Ad&ress Apartment/Unit #
ç)’c 573OlCity State ZIP Code
Date: tô/7/)
Qt
Legat Name: Zimiga
Last
02/05/1979Date of Birth:
____________________
Address: 4331 Carriage Hills Drive
Brent M
First
503-1 1-5342- Social Security Number:
_____________
M.I.
Street Address
Rapid City SDCity
Phone: 605-348-2342 Fax: 605-348-0108
1. What is your area of expertise in the industry?
Apartment/Unit #
57702State ZIP Code
__________
Emai t:
__________________________
2. How long have you worked in the industry?
3. What is your affiliation with the company? (Owner, partner, employee, etc.) Treasurer4. Have you ever been convicted of a misdemeanor or felony? Yes 2 No If yes, Explain
5. Have you had a License suspended or revoked? D Yes 2 No If yes, Explain
6. I, the undersigned, do hereby submit application for the stated contractor s ticense as the RME(Responsibte Managing EmpLoyee) or Licensee for the firm named herein. I do hereby expressly represent,and warrant, that am acting in capacity of the RME/Licensee of said firm; and I hereby agree to accept theresponsibilities for said company’ s and my own actions in connection with the contractor s License that maybe granted. Yes C No
NICET# NICETLeveI ExpiresIP.E. # Issued Expires
/a/l/t7D.O.T. # Issued ExpiresI
CERTIFICATION (The fotlowing declaration is to be signed by the RME) Pikes Peak Regional BuildingDepartment requires all persons seeking a License to undergo a Criminal Background Check. I herebyauthorize Pikes Peak Regionat Building Department to perform a Criminal Background Check utiLizinginformation prDvided on this application. I agree and understand Pikes Peak Regionat Building Departmentmay deny me a license after reviewing my Criminal Background Check. If any information provided on thisapplication is untrue, ticense granted to me is automaticatly revoked.
Print name & title (RME): /rt.,i c vt —
Signature of (RME): Date: ta sit 7
- .‘ -L(v fri
Company Position To From
J
5
Rapid Fire Protection Inc.1530 Samco Road. Rapid City, SD. Phone: 605.348.2342. Fax: 605.348.0108
October 6, 2017
Pikes Peak Regional Building Department2280 International CircleSte 100Colorado Springs, CO $0910
To Whom It May Concern,
I am writing to you in-regards to our licensed RME for our Licensed ID #2 1676 Building
7-A (fSC-A).
We currently have Hue Phan as our RME. Upon the completion of licensing
Brent Zimiga as our RME we ask you to please remove Hue Phan.
Sincerely,
Matthew HammonPresident
Brent Zimiga
Experience:
July 2002 — Dec 2007 Rapid Fire Protection, Inc. - Designer/Project Manager
Responsible for performing sprinkler system layouts, hydraulic calculation, and pipe sizing underthe supervision of a Registered Professional Engineer. Also prepared material lists, placed orders,and scheduled shipment of products to job site. Tracked day-to-day progress of projects, evaluatedinstaller performance, and tracked overall profitability. Helped with pre-bid layouts, interpretationof project documents, and code evaluations. Relevant duties included:
• Detailed Design of Fire Sprinkler Systems, Fixed Water Spray Systems, fire Pump Systems,and Foam Systems.
• Preparation of suppression system shop drawings and hydraulic calculations.• Performance of job site inspections to determine compliance of systems installation per
contract documents and all relevant codes and standards.
Dec 2007 — Present Rapid Fire Protection, Inc. - Design Manager
In responsible charge of all design department work. Reviewed all drawings and calculationsperformed by Rapid Fire. Work as Engineer of Record on numerous design build projects. Designedand project managed 75 separate projects including Federal, Military, Core of Engineers,Residential, Commercial, Industrial, and Special Hazards Systems. Relevant duties included:
• Detailed Design of Fire Sprinkler Systems, Fixed Water Spray Systems, Fire Pump Systems,and foam Systems.
• Preparation of suppression system shop drawings and hydraulic calculations.• Performance of job site inspections to determine compliance of systems installation per
contract documents and all relevant codes and standards.• Building and Fire Code Analyses and Design Coordination• Fire Protection Design Analysis• NfPA Standards Compliance• Life Safety Code Applications• Special Occupancy Standards• Special Hazards Detection, Alarm, and Suppression Systems
Specific Jobs Designed and Managed in Colorado.
ContractJob Name Location AmountDenver VA Medical Center Aurora, CO $8,050,992.00EMCH Nursing OB Expansion Brush, CO $112,977.00
GreenwoodVillage Center Station Ill Village, CO $1,283,402.00
Ft. Morgan,Ft. Morgan Middle School CO $369,365.00
Fort Collins,The Grove at Ft. Collins CO $358,185.00CU Recreation Facilities Boulder, CO $649,027.00
Fort Collins,Legacy Senior Residence CO $239,485.00
New Raymer,Prairie PK-12 School CO $143,289.00
Rapid Fire Protection Inc.1530 Samco Road. Rapid City, SD. Phone: 605.348.2342. Fax: 605.348.0108
10/02/2017
Pikes Peak Regional Building Department2880 International CircleSte. 100Colorado Springs, CO $0910
To Whom It May Concern,
RE: RME Applicant
I am writing in-regards to Brent Zirniga and his application to be an RME for our Contractor Number of #21676.
Brent is a Full-lime employee with our company and we ask you to please add him as an RME.
Sincerely.
Matthew Hammon
President
Page 1
9
OFFICE OF THE SECRETARY OF STATEOF THE STATE OF COLORADO
CERTIFICATE OF FACT OF GOOD STANDING
I, Wayne W. Williams, as the Secretary of State of the State of Colorado, hereby certify that,according to the records of this office,
RAPID FIRE PROTECTION, INC.
is an entity formed or registered under the law of South Dakota has complied with allapplicable requirements of this office, and is in good standing with this office. This entity hasbeen assigned entity identification number 20031114091
This certificate reflects facts established or disclosed by documents delivered to this office onpaper through 09/27/2017 that have been posted, and by documents delivered to this officeelectronically through 09/28/2017 @ 11:33:49
I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, and issued thisofficial certificate at Denver, Colorado on 09/28/20 17 @ 11:33:49 in accordance with applicable law.This certificate is assigned Confirmation Number 104715 19
Secietan’ of State of the State otColoiado
*********************************************End ofCet1ificate******************************************Notice: A certiflcate issued electronically front the Colorado Secretary ofState a Web site is
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DocuSign Envelope ID: 4288FD30-BC91 -4B5E-9777-DC53A960338C
AmRDCERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the policyfies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsement(s).
PRODUCER 1-605.-336-1090 CONTA6T
Holmes Nurphy & Asaoc-SF i1iWEhs.U:
5120 5. Solberg Ave--
—-
Sioux Falls, SD 57109 INSURER(S) AFFORDING COVERAGE- - NAIC# -
INSURER A: Hartford Fire Insurance CompanyINSURED
INSURERS: Travelers Property Caeualty Co. AnrericaRapid Fire Protection, Inc.
—-•—----- .. —
INSURERC: Twin City_Fire Insurance Co
15 30 Sanrco Rd tNSURER 0
Rapid City, SD 57702 !i/RE -- —______-- —
INSURER F:
COVERAGES CERTIFICATE NUMBER: 49445062 REVISION NUMBER:
A GENERALLIABILITY 91UENOEO211 04/01/17 O4/O1/lBEACHOCCURRENCE $1,000,000AENfEOCOMMERCIAL GENERAL LIASILITY
- 0 ynrropranre 3OG, 000
CLAIMS-MADE [ J OCCUR MED EXP (Anyone person) - $10,000
PERSONAL&ADVINJURY 1,000,000
i -- -___________ GENTRALAGGREGATE 2,000,000GENt AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGO $ 2 • 000, 0001 POLICYr1 X
-------- $
A AUTOMOBICEUAOILITY — — 91UEN050212 04/01/11 04/01/18 OMINEDsINGLELIMlT1 000 000
X ANY AUTO CDILY INJURY Per person)- ALL OWNED SCHEDULED
BODILY INJURY )PeracDden$ - — —______
X I NON-OWNED—
._ HIREDAUTOS AUTOS (PecdSen() - - -
I $B X UMBRELLACIAB IXJOCCUR — ZUP91M4468217NF 04/01/17 O4/O1/lBjLA0CcE$1o.ooo.ooo
XCESSLIAs- CLAIMS-MADE AGGREGATE - $10,000,000
DED X IRETENTIONSO,000 — — $c WORKERSCOMPENSATI0N
91WB0E0210 04/01/17 04/01/18 xp WCSTATJ- I 0TH-AND EMPLOYERS LIABILITYY I N - IQEYLJMITE -
ANY PROPRIETOR]PARTNERJExEcUTIvEEL EACH ACCIDENT I 1, 000 , 000OFFICERJMEMBER EXCLUDED? N N(A
-- -- — -•-•
———--—- ——I --
-
(Mandatory In NH)EL DISEASE
- SA EMPLOYE $ 1, 000,000((yes, tescribe under I 7 — - -DESCRIPTION OF OPERATIONS Sciow EL DISEASE. POLICY LIMIT 5
DESCRIPTION OF OPERATIoNS (LOCATIONS! VEHICLES (Attach ACORD 101, AddItIonal Remarka Schedule. if more space (a required)RE: Contractors License
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOREPikee Peak Regional Building Department THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
2800 International CircleAUTHORIZED REPRESENTATIVE
Colorado Springe, CO 80910
USA
DATE IMM/DD[YYYYI03/28/2 017
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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 IADDL:SUBRr POCICYEFF POLICYEXPLTR TYPE OF INSURANCE I ceo r v.njn I POLICY NUMBER IMM!ODtfYVYI IMMIOrJIYYVYI LIMITS
ACORD 25 (2010/05)CThnansf49445062
© 1988-2010 ACORD CORPORATION. All rIghts reserved.The ACORD name and logo ate registered marks of ACORD
1 7-S-01 341
‘Be ‘It ‘I(nown ‘ihat
Rapid Fire Protection, Inc.Matthew Hammon-Principal
‘I-ts Successfully ComyltedllRec1uIrernentsto Becorne Re8Isterec(
Fire Suppression Systems Contractor
‘lsstied On
January 1, 2017
Expirin On, ltnIess Eariier Revo1ec(
December 31, 2017
hi ccordance With8 CCR 1507-11
Fire & Life Safety SectionDivision of Fire Prevention & Control700 Kipling Street, Suite 4100Denver, CO 80215
3rMike Morgan, Director
Public WorksBuilding Division15151 E. Alameda PkyAurora, CO 80012
303-739-7420
1213800 CONTRACTOR LICENSEDate of Issue: 06/12/2017 Date of Expiration: 07/01/2018License Number: 2017 1308230 00 CLContractor Name: RAPID FIRE PROTECTION INCType of License: Fire Spinkler Systems Contractor
Permits Online User
LICENSING OFFICIAL
It is the licensee’s responsibility to be familiar with the City of Aurora Building Codes Division Chapter 22Building and Building Regulations, Article III Contractors Division 22-61 through 22-102 forcontractor and supervisor licensee responsibilities./
RAPID FIRE PROTECTION INC1530 SAMEO RDRAPID CITY SD 57702
Cut along perforated line
WalletI Duplicate
-lPublic Works Building Division Public Works Building Division
15151
E. Alameda Parkway 15151 E. Alameda ParkwayRO AuRORA, co 80012 AURORA, co 80012PHONE NO. (303) 739-7420 I PHONE NO. (303) 739-7420
Valid through: 07/01/2018 Valid through: 07/01/2018Contractor: RAPID FIRE PROTECTION INC Contractor: RAPID FIRE PROTECTION INC
Type of License: Fire Spinkler Systems contractor i Type of License: Fire Spinkler Systems ContractorLicense #: 2017 1308230 00 CL License #: 2017 1308230 00 CL
A signed license by license official should be A signed license by license official should bemaintained in your files, maintained in your files.
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CONSTRUCTION SUPERVISOR -- FIRE SPRINKLER
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November 5, 2016
&jw!i’,i November 5, 2018
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State ofNorth DakotaSECRETARY OF STATE
CONTRACTORS LICENSE RENEWAL
NO: 32379 CLASS A
I, Alvin A. Jaeger, Secretary of State of the State of North Dakota, andas Registrar of Contractors, certify that RAPID FIRE PROTECTIONINC. whose address is Rapid City, SD has tiled in this office properapplication for Renewal of Class A Contractor’s License valid to March1, 2018, and has paid the required fee, and has complied with allrequirements of Chapter 43-07, North Dakota Century Code.
RAPtD FIRE PROTECTION INC. therefore, is entitled to bid on andaccept contracts as authorized by law, under this license, without limitas to value of any single contract.
Dated January 30, 2017
a/9Z9cA-
Alvin A. JaegerSecretary of State
rCONTRACTOR*
STATE OF MONTANADEPARTMENT OF LABOR & INDUSTRY
*CONSTRUCTION CONTRACTOR REGISTRATION UNIT
CERTIFIcATE OF
CoNTRAcToR REGISTRATION
REosTRATJoN Not,36784
RAPID FIRE PROTECTION INC
1530 SAMCO ROADRAPID CITY, SD 57702
Effective Date: Jul 19, 2016Expiration Date: Jul 18, 2018
No Employees - May Hire Exempt Workers Only
i-dd ticitil informa hon on hack. Please notify th agency of any changes within 10 days.
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Business Name:License Number:Classification Type:Issue/Expiration Date:
BUILDING SAFETY DEPARTMENT2101 ONei1 Avenue Suite 202
Cheyenne, WY 82001
Building Contractor! Trade License
RAPID FIRE PROTECTION, INCCT-i 8-08343Class F-i - Sprinkler (fire)/Standpipe05/19/17 05110/18
1 c\&
Justin DupuyChief Building Official
20
Number: 166CLASS C
_______
FIRE SUPPRESSION/SPRINKLER SYS
KNOW ALL MEN BY THESE PRESENTS, that, pursuant to and under the laws of the State of Wyoming and the Ordinances of the City of Cody,Wyoming this license is granted to conduct and operate within the corporate limits of the City of Cody, Wyoming. This license is granted underand especially subject to the provisions and conditions of Ordinance Title 9 Chapter 3 and is good until the date stated below unless previouslyrevoked or suspended in accordance with the provisions of said Ordinance.
IN WITNESS WHEREOF the Council of the City of Cody has caused this d and aealed on this date of 11/28/2016
?:; D7N(fl7
thor ed Signature
Valid Through: 12/31/2017
ijCtrY OP CODY
WYOMING
CITY OF CODY, WYOMINGContractor License
Issued To: RAPID FIRE PROTECTION, INC1530 SAMCO ROADRAPID CITY SD 57702
:
— —
22
PIKES PEAK REGIQNAL Bft. PING PEPARM1I.
Fire Alarm Contractor License Application(RBD USE ONLY
It is requested that the Fire Board of Appeals of the Colorado Springs Fire Department Date f _DLfr)L7consider this application for the state license in compliance with the Pikes Peak Regional Building Code. Initiaj
FIRE ALARM CONTRACTOR LICENSE REQUESTED (Chcck one) I(7 IFAC-A o FAC-B
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Type of Entity (Check one) El Individual El Partnership El Corporation El LLC
Business Name: Complex Technologies LLC(The business name is the name that will appear on the license and is the actual name under which the contracting business will operate.)
Federal EmpLoyer Identification Number: 475598792
Business Address: 4700 Tyler PlaceStreet Address Apartment/Unit if
Springdale Ar 72764City State ZIP Code
Business Phone: 479-231 -91 Business Email: [email protected]
Business Fax:
______________________________________
Business Website:
_________________________________
Company’s Principat Officers, Partners, or Owners
Name: ]ohnathon Mattingly Title: Operations Manager
Name: Philip Davis Title: Operations Manager
1. Number of years company has operated as a contractor? (If new, write “new”) 2.5
2. Type of work performed? (Check one or both, if applicable) El Residential 0 Commercial
3. Has the company ever been named in or responsible for any entered and unsatisfied judgments, liens,and/or ctaims against them in which the company was the contractor? El Yes El No If yes, Explain
4. Has the company been a defendant in a coltection action court case? El Yes El No If yes, Explain
5. Has the company ever declared bankruptcy? C Yes El No If yes, Explain
6. Has the company ever had a license suspended or revoked? El Yes El No If yes, Explain
7. Has the company ever defaulted on a contract? C Yes El No If yes, Explain
—-• -- •••-“•--
Jurisdiction - License type and number Jurisdiction- License type and number
Arkansas Fire Alarm Contractor License #2460Arkansas Secuirtv Systems Contractor Lic #E00002460ASAA Certified Level 2 A&B Fire & Advanced Electronics
23
Project History (List projects in which this company worked as the contractor.)
1. Project Street Address: 2002 Oxford Way - Oxford Mississippi
Type of work (check one) El Residential ElCommerciat
Cost: $268,000 Date: 02201 5 Your position: Fire Alarm Contractor
Describe Job in detait: Fire Alarm and Security Access Installation
2. Project Street Address: 1 00 Dawg Drive - Starksville Mississippi
Type of work (check one) El Residential ECommerciat
Cost: $301 ,400 Date: 08-2015
Describe Job in detail: Fire Alarm, Access Control, Cameras - large student housing
3. Project Street Address: Beacon of Light - 1002 SW I Street - Bentonville Arkansas
Type of work (check one) El Residential ECommercial
Cost: $90,000 Date: 07-201 6 Your position: Fire Alarm/Low Voltage Contractor
Describe Job in detail: Daycare - Fire Alarm Install - Cabling for Computers
Stadium View Apartments - 2508 East Johnson Ave - Jonesboro Arkansas4. Project Street Address:
_________________________________________________________________________
Type of work (check one) El Residential ECommercial
Cost: $246,000 Date: 11 201 6 Your position: Fire Alarm Contractor
Describe Job in detail: Install Fire Alarm System
5. Project Street Address: Dickson Tower - 609 West Dickson - Fayetteville, Arkansas
Type of work (check one) El Residential ECommercial
Cost: $47530 Date: 05201 7 Your position: Fire Alarm Contractor
Describe Job in detail: Update and reinstall replacement voice Evac System
CERTIFICATION (The following declaration is to be signed by the principal officer of the company) The undersigned, onbehalf of the company, partnership or corporation, does hereby declare and warrant that the “examinee” for acontractor’s license named herein has the express authority to bind the company, partnership, or corporation by thisapplication; and further, the company does hereby agree to abide by the ordinances and regulations promulgated by thecity of Colorado Springs, El Paso County, and those adopted by the municipal entities within El Paso County in regard toany work which may be performed by our company pursuant to the contractor license for which this application ismade.
Print name and pra,anage0h than Mattingly
Signature:// J
____
1/Date: f’/7/7
Fire Alarm/Low Voltage ContractorYour position:
24
Licensee Information
1. What is your area of expertise in the industry? Fire Alarm Design, Installation, and Service.
2. How tong have you worked in the industry? 25 years
3. What is your affiliation with the company? (Owner, partner, employee, etc.)Employee I Project Manager
4. Have you ever been convicted of a misdemeanor or felony? El Yes El No If yes, Explain
5. Have you had a license suspended or revoked? El Yes El No If yes, Explain
6. The examinee understands that direct supervision and control includes any one or a combination of thefollowing activities: supervising, managing construction activities by making technical and administrativedecisions, checking jobs for proper workmanship, or direct supervision on job sites. Will you, as thequalifying individual, perform one or more of these duties? El Yes El No
Certifications
Expires04-01-2020
Expires
Work History
Company Position To From
Complex Tech Project Manager Present 2-2017Dunk Fire Senior Service Manager 4-2& 2OSimolex Grinnel Service ManaQer 2-1 999
CERTIFICATION (The following declaration is to be signed by the Licensee) Pikes Peak Regional BuildingDepartment requires alt persons seeking a license to undergo a Criminal Background Check. I herebyauthorize Pikes Peak Regional Building Department to perform a Criminal Background Check utilizinginformation provided on this application. I agree and understand Pikes Peak Regionat Building Departmentmay deny me a license after reviewing my Criminal Background Check. II any information provided on thisapplication is untrue, license granted to me is automatically revoked.
Print name a title (License . urn E. Anthony - Project Manager
Signature of (Licensee):
2880 International Circle, Colorado Springs, CO 80910 Telephone 719-327-2887 Fax 719-327-2951
Legal Name: Anthony
Last
Date of Birth: 12-14-64
Tim
Address: 21696 East 495 Road
E
First Mi.
Social Security Number: 479963285
Phone: 479-231-9111
Street Address Apartment/Unit #
Colcord OK 74338City State ZIP Code
Fax: Email:[email protected]
NICET# NICET Level
#113211 IVP.E. # Issued
ID.0.T. # Issued Expires
I
Date: /:) /7-17
25
Responsible Managing Employee (RME) Information
Legat Name: Anthony Tim
Last
12/14/64Date of Birth:
_________
Address: 21696 East 495 Road
City
Phone: 479-231-9111
____
Fax:
E
First M.I.
479963285Social Security Number:
_________________
State ZIP Code
_______________
Emait:
____________________-
1. What is your area of expertise in the industry? Fire A’arm Design, Installation, and Service.
2. How tong have you worked in the industry? 25 years
3. What is your affiliation with the company? (Owner, partner, employee, etc.)Employee / Project Manager
4. Have you ever been convicted of a misdemeanor or felony? D Yes 0 No If yes, Explain
5. Have you had a ticense suspended or revoked? D Yes 0 No If yes, Explain
6. I, the undersigned, do hereby submit application for the stated contractor’s license as the RME(Responsible Managing Employee) or Licensee for the firm named herein. I do hereby expressty represent,and warrant, that I am acting in capacity of the RME/Licensee of said firm; and hereby agree to accept theresponsibilities for said company’s and my own actions in connection with the contractor’s license that maybe granted. D Yes D No
Certifications
NICET# NICETLevet Expires! #113211 I IV 04-01-2020
P.E. # Issued Expires
t ID.O.I. # Issued Expires
Work History
Company Position To From
Complex Tech Project Manager Present 2-2017
Dunk Fire Senior Service ManaQer 4-2005
SimDlex Grinnel Service Manaaer 2-1 999
CERTIFICATION (The following declaration is to be signed by the RME) Pikes Peak Regionat BuitdingDepartment requires all persons seeking a license to undergo a Criminat Background Check. I herebyauthorize Pikes Peak Regionat Building Department to perform a Criminal Background Check utilizinginformation provided on this application. I agree and understand Pikes Peak Regional Building Departmentmay deny me a license after reviewing my Criminal Background Check. If any information provided on thisapplication is untrue, license granted to me is automatically revoked.
Print name & title (pJ)I[m E. Anthony
Signature of (RME):
Street Address Apartment/Unit #
Colcord OK 74338
- Project Manager
Date: 72 / -/7
26
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THIS LtCENSE MUST BE CONSPICUOUSLY DISPLAYED IN PLACE OF BUSINESS
,1 A%s>LLiceh1seJ__<
This is to certify thatComplex Technologies, LLC
is duly licensed to transact business in the State ofArkansas as aClass E License: Alarm SvsteTns Company - Unrestricted
This license is renewable as provided in A.c.A.1740-101 Et. Seq.
Number
CMPY.00024(Q]
Date of Expiration
L 03/03/2018]
Arkansas State Police
h
Sergeant Michael MoyerAdministrator
NON ‘CRNSFERABLE
28
Tim E. Anthony21696 East 495 Road
Colcord, OK 74338
PROFILE
NICET IV - Fire Protection Engineering Technology # 113211
E X PER I E N CE
COMPLEX TECHNOLOGIES LLC - SPRINGDALE, AR
Project ManagerFEBRUARY 2017 - PRESENTResponsible for design & project management of lire alarm system installations. Trackjob site progress and use my experience and knowledge to better the company andother personnel. Implement procedures to maximize company profitability.
DUNK FIRE & SECURITY -SPRINGDALE, ARSenior Service ManagerAPRIL 2005 - FEBRUARY 2017
Hired to help build Service Department in new start-up company. Worked on buildingdepartment from scratch and setting up processes and procedures to pass to newmanager. Worked in Install department as Senior Project Manager. Tracked job siteprogress and coordinated materials and manpower to facilitate profitable jobcompletions. Programmed panels at job sites and inspected with Fire Marshal atcompletion of jobs. Designed systems to optimize performance and minimize cost tocustomers. Attended industry seminars to maintain certifications and continued seekingadditional training to better myself and the company.
SIMPLEX GRINNEL - BETHEL HEIGHTS, AR
Service ManagerFEBRUARY 99 - APRiL 2005
Trouble shot and programmed panels and systems with large company. Obtainedvaluable experience and certifications. Trained co-workers to follow guidelines set forthbe NFPA and the company to ensure quality installations that met code and companystandards.
REFERENCES
Nick Pianalto Complete Audio Visual 479-799-9994
Clay Kendrick Carson Engineering 479-236-5238
Josh Magnuson Brookendale Services 479-871 -6082
Cody Fow Elliott Electrical 501-326-1445
29
czrOctober 10, 2017
( fLip I >4700 Tyler Place
Springdale, Ar 72764
479-231-9111
Pike’s Peak Regional Building Department
Colorado Springs Fire Department
2880 International Circle
Colorado Springs, CO 80910
Regarding: Responsible Managing Employee fRME)
To Whom It May Concern:
Please accept this letter as confirmation that Tim Anthony, the Responsible Manager Employee (RME) is
an exclusive full-time employee of Complex Technologies LLC.
Please feel free to contact me if you have any questions of concerns.
Sincerely,
JC Mattingly
Owner/Partner
Complex Technologies LLC
Mobile: 479-387-4703
‘I /—
/ / I
OFFICE OF THE SECRETARY OF STATEOF THE STATE OF COLORADO
CERTIFICATE OF FACT OF GOOD STANDING
I, Wayne W. Williams, as the Secretary of State of the State of Colorado, hereby certify that,according to the records of this office,
Complex Technologies LLC
is an entity formed or registered under the law of Arkansas has complied with allapplicable requirements of this office, and is in good standing with this office. This entity hasbeen assigned entity identification number 20171765747
This certificate reflects facts established or disclosed by documents delivered to this office onpaper through 10/18/2017 that have been posted, and by documents delivered to this officeelectronicallythrough 10/19/2017 @ 10:21:42
I have affixed hereto the Great Seal of the State of Colorado and duly generated, executed, and issued thisofficial certificate at Denver, Colorado on 10/19/2017 @ 10:21:42 in accordance with applicable law.This certificate is assincd Confirmation Number 1 0505471
******************************************E!d ofCertiticate*************************************Votice: A certifIcate issued electron icatlv front the Colorado Secretan of State s O’’h site is fat/v and immediate/v ia/in ana’ eulectoe. Hmceie,’,as an option, the issuancnr and i’alidth of a certificate obtained c/cc tronicath’ mat’ he ettablished 1w visiting the raIL/are a Certificate page attift? Secreraci 01 State ‘1 [feb site, htt1 / lot it /0t thIn c) i/c /t1 (i’.’ ti/In !!t hcnti’chC ZOO/cl do enlerins the cent//cole t confirmation numberthsplaved on the certiJic’ale, and fofimning the rnstruct,nn.s n/i /jlmcd Qf,ffit’piiI1g_ the issuance of a certificate is lunch optional and is not,,ecessai to the ia/ui and effective issuance ot a certificate Pt,,’ tune injoi’malmn, vicit our 0db /ite, hrrp ri ictc ai ct,ileco us click‘‘Bi,cinessc’s. trutle,narks, truth’ ndmc’v ‘‘ and sc’kct “Frequentlt’ Asked Ouccnons,
Searetar of State of the State tf’ f,/
A3RD CERTIFICATE OF LIABILITY INSURANCE
THIS CER17FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON ThE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY ThE POLICIESBELOW. ThIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN ThE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND ThE CERTIFICATE HOLDER.
IMPORTANT: If the certificate hotder Is an ADDITIONAL INSURED, the poilcy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject tothe terms and conditIons of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder In lieu of such endorsement(s).
— CONTACTPRODUCER NAME. Stan Wright
Stan Wright PHONE 479.659.4568 FAX(NG.No. Exti: I (NC. No):EMNL3701 S Pinnacle Hills Pkwy AflDRESS: [email protected]
Suite 200 INSURER(S) AFFORDING COVERAGE NAIC C
ROgers AR 72758 INSURER A: American National Property and Casualty 28401INSURED iNsURER B: Forernosi Insurance 17185
Complex Technologies, LLC INSURER C:
4700 Tyler Place INSURER 0:
SpringdaIe, AR 72764 INSurER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER REVISION NUMBER:
LNSR— TYPE OF INSURANCE
.IOi I cyF poucy EXFouc NUMBER I ØIaflJyyyy) (fl5YYYY) LIMITS______________
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE — $_CMMADE OCCUR ) S
MED EXP (My ore person) S
PERSONALaADv1NJURY S
GEN’L AGGREGATE UMrr APPLIES PER: GENERAL AGGREGATE 5
poucy [] PRODUCTS - COMP/OP AGG $JECT L_J CCC
1OTEER: — — $
AUTOMOBILE LIABILITY COMBINED SINGLE uurr $ 1 OI3C)0CJlj(Es acddent)
ANY AUTO BODILY INJURY (Per person) S
A — ALLOWNED X SCHEDULED 0301C0019 09/0112017 09/01/2018 BOOICYINJURY(Poradeiit) SAUTOS AUTOS
X HIRED AUTOSPROPERTY DAMAGE $UTOS (Per adent)
S
OCCUR EACH OCCURRENCE $UMBRBL H CMMADE AGGREGATE $EXCESS UAS
DED I I RETENTiONS — SWONKERS COMPENSATION I PER I 0TH-
I_STAnsrE_I I_ERAND EMPLOYERS’ UASR.rrY y I N1000,000ANY PROPR)ETORIPARTNERJEXECUOVEB OFF1CERIMEMBEREXCLUDED? [7 NJA 012555506 11/02/2017 11/0212018 E.LEACHACCIDENT S
(Umidatoly In NH) E.L DISEASE - EA EMPCOYE $ 1.000,000If yes. desatbe underDESCRIPTION OF OPERATIONS below — — ILL DISEASE. POLICY UNIT s 1.000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VENICLES (ACORD 101, AdditIonal Remarks Schedule, may be attached If more space Is requIred)
Audio/Visual installation
CERTIFICATE HOLDER CANCELLATION
DATE (MWDO1YYYY)
1017112017
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO ThE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWiTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTh RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AU. ThE TERMS,EXCLUS1ONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Pikes Peak Regional Building Department
2680 International Circle
Colorado Springs, CO 80910
ACORD 25(2014/01)
SHOULD ANY OF ThE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOREThE EXPIRA17ON DATE ThEREOF. NOTICE WILL BE DELIVERED INACCORDANCE WITH ThE POLICY PROVISIONS.
55 REPRESENTATiVE
—7
The ACORD name and logo are register(014 ACORD CORPORATION. All rights reserved.
KS of ACORD
32
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTiFIcATE AS A MATTER OF INFORMATtON ONLY AND CONFERS NO RIGHTS UPON ThE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATiVELY AMEND, EXTEND OR ALTER ThE COVERAGE AFFORDED BY ThE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN ThE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.IMPORTANT: If the certificate holder Is an ADDONAL INSURED, the potlcy(Ies) must be endorsed. If SUBROGATION IS WANED, subject tothe terms and condItions of the polIcy, certain poticles may requtre an endorsement A statement on thIs certificate does not confer rights to thecertificate holder In lieu of such endorsement(s).
OBNIAEYPRODUCER rAss Stan WrightStan Wright PHONE 479.659.4568 I FAX
(NC. No. EzH: I (NC. No):E-MAIL3701 S Pinnacle Hills Pkwy .DDRESS: [email protected]
Suite 200 INSURERt5) AFFORDING COVERAGE INC SRogers AR 72758 INSuRER A: American National Property and Casuatty 28401
INSURED INSURER B Foremost Insurance 11185Complex Technologies, LLC SUP.ER C:
4700 Tyler Place INSURER 0:
Springdate, AR 72764 INSURER E:
tNBURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
ABbi Ubi POLICY EFF POUCY EXPRTYPE OFINSURANCE we - POUCY NUMBER (MWOOJYYYY) tMWDDlYVYY COSTS______________
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE To RENTED
OCCUR PREMISES tEa orrca $CMMAoE
PERSONAL & ABe IN,NRY $
MEDEXP(Myonepoiaon) $
GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
L] PRO- L] LOC PRODUCTS - COUPIOP AGO $JECT
——
AUTOMOBILE UABIUW COMBINED SINGLE LIMIT $ 1,000,000— lEa ecddanl)
ANY AUTO BODILY ILiURY(Ppeiaon) $
A ALLOWNED x SCHEDULED 0301C0019 09/0112017 09(01(2018 eOoIcYeURvPuracdor.I) SAUTOS AUTOS
X HIREDAUTOSNON-OWNED PROPERTY DAMAGE $trIOS tPet edenI)
S
UMBRELLA LIAb f—H OCCUR EACH OCCURRENCE $EXCESS UAB CLAIMS-MADE AGGREGATE $
DED I I RETENTiONS — $,‘dC.,..ERS COMPENSATION FPER I I 0TH-
I_STATUTE_I I_ERAND EMPLOYERS LIABILITY ,,, N1,000,000ANY PROPRIETORIPARTNEWEXECUGvEB OFFIcER,UEMBEREXCCUDEO7 fl NIA 012555506 1110212016 1110212017 E.LEACHACCIDENT $
(Mandato,y In NH) EL DISEASE - EA EMPLOVE $ 1,000,000If yea. dasaibe underDESCRIPTION OF OPERATIONS below — El. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddItional Remarki Sctwdule, may be attached 11 more space Is reqtdred)
Audio/Visual installation
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF ThE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOREThE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH ThE POLICY PROViSIONS.Pikes Peak Regional Building Department
2880 International CircleAUTHORIZED REPRESENTATWE
Colorado Springs, CO 80910—
DATE Pi(WDD(YYYY)
101f 12017
ThIS IS TO CERTIFY THAT WE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Alt. THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1988-2014 ACöRD CORPORATION. All rights reserved.ACORD 25 t2014101) The ACORD name and logo are reglste rks of ACORD
33
AcrnIZCERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE 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 tothe terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to thecertificate holder in lieu of such endorsernenttsL
PRODucER cONTAcTJonathan Curtis
Sims & Renner Insurance PHONE FAX — —_________
P0 Box 9930 (NC, No, Extl: 479-684-4100 (NC, No): 4796844111Fayetteville, AR 72703 iss: [email protected] -Greg Sims —_________________
INSURER(S) AFFORDJG cOVERAGE NNC # —
INSURER A: Employers Mutual 21415INSURED Complex Technologies LLC INSURER B:
2410 Frontage Rd Ste 23Fayetteville, AR 72703 INSURERC:
INSURERD:
INSURERE:
INSURERF: I
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE 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.
A X COMMERCIAL DENERAL LIABILITY EACH OCCURRENCE S 1,000,00’—
-
, CLAIMS-MADE •“ OCCUR 5D42214 01/1512017 0111512018 PP1lSESfEacccLi_
MED EXP lAny one person( 5 5,00’: PERSONALSADVINJURY S 1,000,00
GEN’L AGGREGATE LIMIT APPLIES PER,
GENERAL AGGREGATE S 2,000,00
POLICY L r C LOC [pUCTS_COMP/OPAGGS - 2 000 00(
OTHER —
AUTOMOBILE LIABILITY [
L ANY AUTO BODILY INJURY (Per person) S
H ALL OWNED 1 SCEOULED BOO YURYera_cidenS -
I NON-OWNED PROPERTY DAMAGEL_ HIREDAUTOS C AUTOS , eracjfl)L. _____________
• —
L Xi UMBRELLALIAB LJ OCCUR EACH OCCURRENCE S 2,000,001A I EXCESS LIAB C CLAIMS-MADE 5J42214 01/15/2017 01115/2018 AGGREGATE 2,000,001
DEO RETENTIONS ThWORKERS COMPENSATION ‘ PER 0TH-AND EMPLOYERS LIABILITY Y/N
STATUTE ER
ANYPROPRIETORVARTNERIEXECUTIVE I EL. EACH ACCIDENT SOFFICERMEMBEREXCLUOED? N/A i——
, (Mandatory In NH( CE L DISEASE - EA EMPLOYEE SI/yes, describe under ‘DESCRIPTION OF OPERATIONS below I ‘ ‘ EL DISEASE - POLICY LIMIT S
A EquipmentFioater 5A42214 01/15/2017 01/15/2018 Installat 25,001
‘Sm Tools 10,001
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mote space is required(
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE• THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Pikes Peak Regional Bldg Dept ACCORDANCE WITH THE POLICY PROVISIONS.2880 International CircleColorado Springs, CO 80910 AUTHORIZED REPRESENTATIVE
COMPT-1 OP ID: TO
DATE (MM/DD/YYYY1
10/1112017
INSRLTh TYPE OF INSURANCE
P,UUL UbftINSO WVD POLICY NUMBER
POLICY EFF POLICY EXP““YYI IMMIDD/YYYYI LIMITS
© 1988-2014 ACORD CORPORATiON. All rights reserved.ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
34