phone: 404- -9602 engineering / inspections www ... · 2 martin luther king jr., dr., suite 920,...

SAFETY FIRE COMMISSIONER COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

John F. King, Commissioner 2 Martin Luther King Jr., Dr., Suite 920, West Tower, Atlanta, GA 30334

www.gainsurance.org Phone: 404-657-9602 ◊ E-mail: [email protected] ENGINEERING / INSPECTIONS

License And Permit Renewal For Portable Fire Extinguisher; Fire Suppression Business & Water-Based Fire Protection Systems GID-221-SF JUL2019

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 920, Atlanta, GA 30334 - Phone 404-656-2056. 1

INSTRUCTIONS: Fill in ALL boxes, put NA if it does not apply to your company. Print and sign required pages then SCAN & Email to [email protected] along with your renewal, and your company letter and all required documents. DO NOT MAIL DOCUMENTS, include them in your email scan. ONLY MAIL YOUR COMPANY LETTER AND CHECK to the lockbox (Save a copy of this renewal form). No paper forms will be accepted on renewal.

BUSINESS PROFILE Renewal Year Today's Date Amended Fee does not apply if amended at renewal Corporate Name Business Name Phone Fax Physical Address Street City State Zip Mailing Address Street City State Zip Business Email 120-3-23 Business is current with the Georgia Secretary of States Corporation Division? Yes No N/A Is your business address different from your Physical Address or Mailing Address last year? Yes or No Company service tags; collars and labels on file with the SFMO Yes No Tags Reordered? Yes No Expiration Date Yellow Blue Green Red Last Inspection Expiration: Labels Silver Metallic Blue Metallic Collars: Expiration Date Certificate of Liability of Insurance attached Yes No Expiration date: Surplus Lines Affidavit: Yes No Name of requesting officer Title Home Address Street City State Zip Home Phone Email Cell Phone BUSINESS LICENSE RENEWALS (Include company letter with this renewal) FEP= PORTABLES ESP= ENG SPECIAL HAZARDS PEK= KITCHEN CL=SPRINKLER CONTRACTORS PEI= INDUSTRIAL

Business Licenses Types FEP PEK PEI ESP CL Total # Licenses Renewals (Check Box)

Company Letter Duties Performed same: Yes No N/A ADD: Install Service Maintenance Inspect Hydro-static Testing DOT (NEEDS RIN# AND DOT LETTER)

FIRE SUPPRESSION RENEWALS ONLY License Check Box Permit by Type # of

Permits Portable Fire Extinguisher License Portable Fire Extinguisher Permit Pre-engineered Restaurant Kitchen Hood License Pre-engineered Restaurant Kitchen Hood Permit Pre-engineered Industrial License Pre-engineered Industrial Permit Engineered Special Hazard Systems License Engineered Special Hazard Systems Permit Fee of $50.00 per License Total Fee of $25.00 per Permit Total Total Licenses Fees $ Total Permits Fees $

GRAND TOTAL FEES $ Check No:

SPRINKLER RENEWALS ONLY License Check

Box Fee # of License Total Notes

Contractors License $ 75.00 # $ Provide copy of your updated insurance for this license Certificate of Competency License $150.00 # $ Provide Updated NICET copy Grandfathered?

Yes No Designer License $ 75.00 # $

Provide copy of your updated certification for this license Independent Designer License $ 75.00 # $ Inspector License ( waiver)* $ 75.00 # $

GRAND TOTAL # $ Check No:

JHinkley

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Today’s Date: Business Name: License Number: Technician renewal: 1. I have read & understand the Rules and Regulations for which I am renewing. 2. I have a working knowledge of Federal, State and Local laws pertaining to the type of renewal for which I am applying. 3. I am qualified by reason of training, knowledge and experience applicable to the type of permit renewing and have met the 8 hours of continuing education requirement for renewal of this application. 4. I have provided a copy of my continuing education certificate to the business for this renewal 5. I have provided an updated digital photo. 6. I have signed below the renewals for which I am applying. Sprinkler renewals: 1. I have read & understand the Rules and Regulations for the license type(s) I am renewing. 2. I have submitted my updated NICET certificate if expired since last license year. 3. I have a working knowledge of Federal, State and Local laws pertaining to the type of renewal for which I am applying. 4. I have provided sample of my service tags as required. 5. If tags reprinted since last year, I am providing three samples of each for this renewal. INDIVIDUAL ATTESTATION SIGN-OFF

Use Addendum Page If More Lines Are Needed Fire Suppression Water-Based

Total Enter industry code key for each renewal

*Amended means holds permit or license currently and renewing with your company

FEP= PORTABLES PEK= KITCHEN

PEI= INDUSTRIAL ESP= ENG SPECIAL HAZARDS

CL=SPRINKLER CONTRACTORS COC=CERTIFICATE OF COMPETENCY

DL= DESIGNER LICENSE IND DL= INDEPENDENT DESIGNER

IL= INSPECTORS LICENSE

SIGNATURE OF RENEWAL US Citizen

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! THIS FORM WILL ONLY BE ACCEPTED ELECTRONICALLY

Business Name: License Numbers:

CEU - CONTINUING EDUCATION UNITS FORM Include CEU Certificate with this online access to Renewal

EACH TECHNICIAN MUST HAVE 8 HR OF CEU TO RENEWAL PER CEU TYPE CONTINUING ED

CREDITS: I understand that if the rules and regulations require CEU hours to renew that each renewal has met the requirement before requesting this renewal. A list of employees renewing and the number of hours received is provided with this renewal request.

CEU TYPES: FEP= PORTABLES PEK= KITCHEN PEI= INDUSTRIAL ESP= ENG SPECIAL HAZARDS

Renewal Legal Name CEU Training Provider

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Today’s Date:

Business Name: License Number:

RENEWAL APPLICATIONS AFFIDAVIT

This form must be complete by an officer of the business. I understand and authorize the State Fire Marshal Division to verify all documentation submitted by me for these renewal applicant(s). I hereby certify that I am familiar with the Georgia Statutes and the Georgia State Fire Marshal Rules & Regulations relating to these types of renewal applications. And all statements made are to best of my knowledge true and correct. I also understand that any false statements or material misrepresentations on any application may be cause for denial, suspension or revocation of any license or permit requested.

1. I have submitted a current list of applicants name and current home addresses on company letterhead to the State Fire Marshals office for which the company is renewing. 2. Upon request, I will, provide a current digital photo of each technician renewal. 3. My current service tags, labels and collars, which are applicable to the application(s) requested, are on file with the State Fire Marshal Division. 4. If I have reprinted my tags, labels or collars since last renewal year, I will email an electronic color photo of each to the State Fire Marshal Office before renewal. 5. My company is current with the Secretary of States Corporation Division registration; if applicable by rules and regulation. 6. I have provided on company letterhead a list of companies that I subcontract any hydro-static testing service if applicable under the rules and regulation. I certify that the attached list of employees requesting a renewal of their license or permit are employees of this company and have met the requirements of the current rules and regulations for these renewals. 7. I have provided on business letterhead an outline of any changes from last year to this year regarding all applications. My letter a request includes. the following renewals.

If you are not renewing industry type or duties, please provide an explanation in with your company letter.

Signature of Requesting Officer

Title

Date

NOTARY

Sworn to and Subscribed before Me this ______ day of __________________, _____. _______________________________________ _________________________ (Notary Public) (My Commission Expires)

( Seal)





10This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 920, Atlanta, GA 30334 - Phone 404-656-2056. Addendum-1


Addendum-1 Fire Suppression Water-Based









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This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 920, Atlanta, GA 30334 - Phone 404-656-2056. Addendum-2











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! THIS FORM WILL ONLY BE ACCEPTED ELECTRONICALLY

Business Name: License Numbers:

CEU - CONTINUING EDUCATION UNITS FORM Include CEU Certificate with this online access to Renewal

EACH TECHNICIAN MUST HAVE 8 HR OF CEU TO RENEWAL PER CEU TYPE CONTINUING ED

CREDITS: I understand that if the rules and regulations require CEU hours to renew that each renewal has met the requirement before requesting this renewal. A list of employees renewing and the number of hours received is provided with this renewal request.

CEU TYPES: FEP= PORTABLES PEK= KITCHEN PEI= INDUSTRIAL ESP= ENG SPECIAL HAZARDS


H r s

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MO-DY-YR

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MO-DY-YR


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MO-DY-YR

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phone: 404- -9602 engineering / inspections www ... · 2 martin luther king jr., dr., suite 920,...

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