HomeMy WebLinkAboutNotice to Building Official of Use of Private ProviderLOCATIONS.
A Universal GA tom'"''. om
BOWL" A4ine,CA Pon St_Iude.FIL '
Enineerin t:mm�ly.Vk Jadaonwe.Fi tom w
g 9 Lhaibme. NC Knr eim. GA , Fl
SCience8 IMvega�ev Ssaw4ft
Dona. FL. Nlaml, FL. St Pombusg, ft
Com an DekayBeads,ft Ocala.FL. Taff%Afl
P. . Y DoojLasKe,GA Qdind*A mton,GA
Forttslyers; n, Patin Coast. FL . .west Patin Beath FL -
Geatechnlca6L n&terMg l Consuuctlen Materlah Testing and lasyecdons Fat Rerce, FL Passom Ciey: Ft
Building Code Cmnpllance 1 EnvimruaeMel; Heafth i Satety 1 Facilities Consiaing Gat)t Wk; FL Pciham, AL
Notice to- Building Official of Use of Private Provider
Project Name:.. 7-1oc, T:akelanri
Parcel Tax ID(s):
Services to be Provided:, , Plans Review Inspections
lX ' . X'
I,bailc-4the fee owner, affirm I have entered into a contract with.
the Private Provider IndVFA
below to: conduct.the services indicated. above:
Private Provider Firm:International.: .
Private Provider:. Richard Jefferson.. .
Address: .607 NW Commodity.Cove, Port St: Lucie, FL 34986
Telephone: 772-924-3575 ,. Fax: .772-924-3580
E-mail Address: ScheduIin'g0t6amQfa-.com
Florida License, Registration or Certificate No.: Florida License No..'BU 1368
I have elected to use one or more alternative providers to provide building code plans review and/or inspection
services on the building or structure :that is the. subject. of the enclosed permit application; as authorized by
S.553:791, Florida Statutes. I understand that the local building official may not review the plans submitted or
perform the required building inspections to determine compliance with the applicable codes, except to the
extent specified in said law. Instead, plans. review and/or. required building inspections will be performed by
licensed or certified personnel identified in the. application. The law requires minimum insurance requirements
for such. personnel, but I understand that I may:require. more insurance to protect my interests.' By executing
this form, 1 acknowledge_ that -1 have made .inquiry regarding the. competence of the licensed or certified
personnel and the level of their insurance and am satisfied that my interests are adequately protected, I agree
to indemnify; defend, and hold harmless the local government, the local building official,.and'their building code
enforcement personnel from any and all claims arising from my use of these licensed or certified personnel .to
perform' building code inspection services with. respect to' the building or structure that is the subject of the
enclosed permit application.
I understand the Building Official retains authority to review plans, make required inspections, and enforce the
applicable codes within his or her charge pursuant to the standards established by S.553.791, Florida Statutes.
If I make any changes to the listed_ private providers or the services to be provided by those private providers,
I shall, within 1 business day after any change, update_this notice to reflect such changes. The building plans
review and/or inspection services provided by the private provider is limited to building code compliance and
does not include review for fire code, land use, environmental or other codes.
Notice to Building Official_UES BID Form Page 1 of 2 04/19 R1 A
The following attachments are provided as required!
1. Qualification statements and/or resumes of the private provider and all duly authorized
representatives ,
2. Proof of insurance for professional and comprehensive liability in the amount of $1 million per
occurrence relating to all services performed as a private provider, Including tail coverage for a
minimum of 5 years subsequent to the performance of building code inspection services.
Individual
signature
Corporation
Partnership
Print Corpq` o :Name Print Partnership Name
By:
signature(signature)
Print Print Print
Name: Name: Chad Bally _ _Name:
Its: Authorized Signatory Its: --
Address: Address: 3001 Governors Lake or Suite 30DAddress:.
Norcross. Georgia 30071
Telephone Telephone
Nm. No.: (321)27o.s829
Please use appropriate notary block.
STATE OF
COUNTY OF
Individual
Before me, this day of
, 20_, personally
appeared
who executed the foregoing
instrument, and acknowledged
before me that same was
executed for the purposes
therein expressed.
Corporation
Before me, this 17th day of
November .. 20 2o1 personally
appeared Chad Bally
Of w.HFLU
A Corporation, -
on behalf of the state corporation
who executed the foregoing
instrument, and acknowledged
before me that same was
executed for the purposes
therein expressed.
Telephone
No
Partnership
Before me, this day of
. 20- , personally
appeared
Partner/agen -om e a o -
A partnership,
who executed the foregoing
Instrument, and acknowledged
before me that same was
executed for the purposes
therein expressed.
Personally known _ , or produced Identification Type of identification produced
Signature of Notary Print Name
Notary Public. NOTARY STAMP BELOW -
ft
My commission expires: 1 . 1060 r-C Ddoh M010
Notice to Building Officlal_UES BID Form Page 2 of 2 04119 R1.0