HomeMy WebLinkAbout2115_001WEINTRAUB
INSPECTIONS & FORENSIC, INC.
Notice to Building Official of
Use of Private Provider
Project Name: .J L7 1 P- L C, - -7) 0 41 L.C4 L e I.i .
Parcel Tax ID: I , ] 0 1 ' 40 ) , - 00 0 1 - 0 00 -
Services to be provided: Plans Review Inspections,[ [Building_ Pool_ Other_]
Note: If the notice applies to either private plan review or private inspection services the Building
Official may require, at his or her discretion, the private provider be used for both services pursuant to
Section 553.791(2) Florida Statute.
I M cr ---A 70C w I
the fee owner, affirm I have ente d into a contraf.1 with Lie Privarc Provider indicated below to conduct the
services indicated above.
Private Provider Firm: Weintraub Inspections & Forensics
Private Provider: Jerry M Weintraub
Address: 3868 Sun City Center Blvd., Sun City Center, FL 33573
Telephone-. 9 13-633-8000
Fax: 813464-8026
Email Address (Optional): jwolfersberger(a)weintraubinspections.com
Florida License, Registration or Certificate: Professional Engineer 30033
I have elected to use one or more private providers to provide building code plans review and/or
inspection services on the building 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
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 I 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.
3868 Sun City Center Blvd. Phone: 813-633-8000
Sun City Center, FL 33573 Fax:813-4648026
WEIN&TRAUB
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)
Print
Name:
Address:
Telephone
No.:
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
W ,,ji-A f L LLC,
I
Te ephona '
N
Partnership
Telephone
Corporation
Before me, this day of
C� ►r� _ 20A
personally ap ed
of
a
or oration, on
behalf; of the state corporation, who
executed the foregoing instrument and
acknowledged before me that same was
executed for the purposes therein
expressed.
Partnership
Before me, this day
of , 20_, personally
appeared
partner/agent on behalf of
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
My commission expires: 8.S , `1 q
Now t•lAft ono of MWAMO
•caffVemom rift �R M
3868 Sun Cite Center B1%d Sun 2 of Phone: 813-633-8000
Cilv Center. PI 33573 i'ax:813-4648026
FORM # 9B-3.053-2005-01
JOB SITE PRIVATE PROVIDER IDENTIFICATION FORM
Florida Building Commission
Effective February 1, 2006
PROVIDER NO. 1
Primar Contact:
Jon Wolfersber er
Email address
jwolfersberger@weintraubinspections.com
Tele hone Number:
321-474-1459
Fax Number:
813-464-8026
License number
PE 30003.3
Company:
Weintraub Engineering and Inspections, Inc.
Address:
3868 Sun City Center Blvd, Ruskin, FL 33573
Job address
Specific project on job
site
71 O 1'V � Pi�
Permit number
Type of Service Being
Performed:
Building Inspections
Insurance policy
number
GL 10006
r i--
Signed
rovider
PROVIDER NO.2
Primal Contact:
Email address
Telephone Number:
Fax Number:
License number
Company:
Address:
Job address
Specific project on job
site
Permit number
Type of Service Being
Performed:
Insurance policy
number
Signed by
Provider