HomeMy WebLinkAboutNotice to Building Official of use of Private ProviderA Universal
Engineering
Sciences
Company
Geoted*al EngIntraing I Conshudlon Motetlals Testing and Inpedlom
Building Code Compliance IEnyho metrtal,Health6SafetyIFacilitiesConsulting
LOCATIONS
dllafeA GA
Hagm1w.114D
d1a L
Bufo4GA
k.**,CA
Put SLfnde,F1
Chamil1y,Y,1
Jadaarvao,Ft
N-AW
Chaslotte. NC
Vzowl4m. Gh
1ZatF**, FL
Cimiston.FL
Los Vegas, W
S&UotkFL
Daytona, FL
M"1. FL
SC pMmbwg. fl.
DebyBeath,FL
Oealoji.
Tarnpa FL
Doaglasai,GA
OrWo,FL
Tifton,"
FortMyets. FL
p.*m Coast. FL
West pain Sexh, FL
Fat Retce, FL
panama O.Y. FL
Gatnestlle, FL
Nham Al.
Notice to Building Official of Use of Private Provider
Project Name: 7604 Penny T.nne
Parcel Tax ID(s):
Services to be Provided: Plans Review X Inspections X
I, CA JA, the fee owner, affirm I have entered into a contract with
the Private Provider Indicated elow to conduct the services indicated above.
Private Provider Firm: GFA International
Private Provider: Richard Jefferson
Address: 607 NW Commodity Cove, Port St. Lucie, FL 34986
Telephone: 772-924-3575
E-mail Address: Scheduling(@teamgfa.com
Fax: 772-924-3580
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, I acknowledge that I 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 R1.0
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.Corpo . tp . Name Print Partnership Name
By:
• signature (signature)
Print Print Print
Name: Name: Chad Bally _Name:
Its: Authorized Signatory -
Address: Address: 3091 Govemm Lake Dr Suite 30DAddress:.
hla=ow, Georgia 30071
Telephone Telephone
No. No.: (321)27o•se29
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 22u personally
appeared Chad Bally
Of w&IFLud -
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
Partnerlagent-oWbehalf,ot
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
C-4ij.
Signature of Notary Print Name
Notary Public: NOTARY STAMP BELOW
�oiai;t ies.i d't.
My commission expires: ! ' CrMeMw.0 t]eliin
", 1tlr.Celninirilo�.iw� ttglatn
Notice to Building Offlclal_UES BID Form Page 2 of 2 Wig R1.0