HomeMy WebLinkAbout608920- McGahee Notarized NTBForm 11 911-1.0.U.2nnmi
Nolice to littildl,19 W111 lol of
Use of Private Provider
I'lTedhe.lanunrp 20, Joni
h'om — [%An Lktua — 14B NE nrw km Rd
Project \Rnlc: PM S1►um, r I.34903
t41 PSCOR�S M11J
Parcel Tax 1h:
Services to be provided: Plans Review Inspccb:ons
Vote: If the notice applies to eilher private plan review or private inspection services the Building
Official may require, at his or her discretion, Zile private provider be used for both services pursuant to
Section 55 3,791(2) Florida Statute.
1-HERNYWRMCGANEE , the fcc
owner. affitrn I have entered into n contract %with the Private Provider indicated below to conduct the services
indicated above,
Pri\ate Pro\'/der Finn: BERYL PROJECT ENGINEERING.LLC.
Pri\'ate Pro\'/der' — RlCHARD IEDN CANNYN
Address 2810 N 1OTN STREET TAMPA. FL 336o5
Telephone: 813-615-301 Fax: NA
Email Address (Optional): INFOgBERYLPROJECTENGiNEERING.COM
Florida License, Registration or Certificate #: FL PE X 65994
1 have elected to use one or more private providers to provide building code plans review and/or inspection
services on the building thhat 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 inquire 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 harinless 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 that is the subject of the enclosed pennit 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 1
make any changes to the listed private providers or the services to he provided by those private providers,/ shall,
within I business day after any change, update this notice to rellect stuck ciutliges. Tile building plans review
and/or inspection services provided by the private provider is limited to building code compliancy and dsoenot
include review for fire code, land use, environmentn� or other codes,
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The following attachments are provided as required;
1. Qualification statemends and/or resumes of lie private provider and all duly authorized representatives.
2. Proof of insurance for professional and•romp ewnsive liability in the amount of $1 million per
occurrence relating to all services perfonne .as-aprivate provider, including tail coverage for a minimum
of S years subsequent to the perfonnance of building code inspection services.
Individual
1 All'
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gnalure)
Print
Name: t•Q 2'
Address: pu
_1d,0fkA
cicphone
No.:` &-5-�q-IURI
Please use appropriate nolary block
STATE OF
II II,
COUNTY OF i lac
Individual
Before me, this S„ day of
_(01L Yrb- ,20dt personally
appeared L rYt !Plo r y- Me r�jj6tr_r_
who executed dz arcgoing instrument,
and acknowledged before me that same
was executed for the purposes therein
expresscd.
n9mralion P, tncrship
Prr t Corporation Name Print I rtncrship Name
By: By:
signature) (si ature)
Print Nnl
Its: Its;
Address: Ad
'fcicphonc X TelephoneNo. No.:
Co ration Pa ncrship
Before e, s day of Bero m
thic, this
20J of
personally a cared personal l appeared
of
a partner/agent �t —behalf of
cn rAuon, on
behalfof the state core 3tion, who
executed the foregoing ins iment and
ack iowicdgcd before me tha axnc was
executed for the purposes there n
expressed,
day
a partnership, wl executed the
foregoing instnrmen and
acknowledged before r that same
was executed for the pu ses therein
expressed.
Personally known ; or Produced identification _�K Type of identification produced
Signature of Notary Print Name
Notary Public: NOTARY STAMP BELOW CASEY R ELLIS
State of Florida - Notary Public
Commission # HH O
My commission expires: ` 1 7, a
✓� U W My Commission Expires Sept. pi. 03, 2022
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