HomeMy WebLinkAboutNotice to Building Official for use of private provider.pdf4
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Notice to Building Official
Of
AM-
ofPrivate Provider
Pv:act NamKen -and Cathleen Saunders Permit Nurnber
Flarcel '1'ax ID 4502�803mwO038~0001w3
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Services to be provided. PlanReview
Inspections INSPECTIONS
Note:
the
notice applies
t eitherpriv�oiteplan reviewprivateinspectionthe
Bull d is-i
ficial m - requ.i.res,
at hi;,.,.
or her
discretion the
private provider be used �
r;
services' pu-rsuant t�Section _791
log d a. S tatit te.
.� Ken Saunders the fee owner, affirna
I have entered i..rrito a conrracr with the Prn.,'arc Provider indicated below to conduct the services inciicare:d above.
Private.ProviderFirth: Thomas J . Twomey PE
Private Provider Thomas J. Twomey
Address: 2831 Exchange Court, Suite A West Palm Beach, FL 33409
561�686,,5853
tVV0meyengineenng@yahoo.CDM
.. U J. Ajj
'Fllon'da Licf,;-inse R . e istrat' 25626
1 gi ton or Qtrtificaze #r:
have el to use one or n1DtCpriv%ratc provider to provide bu9 cocle ptans- iew ald;oinspection se'rVices O
the building that is the subject of the enclosed pest application, as a .t oii ek F . 553.791) Flork"I'a Statut .'- ,
understand tthe local building official m2y not review thplans submitted of �rfiorm the re1.r }d bu'411dinj�y-
inspections to determine e r planwi..-i the applicable cocks, cxcept to the extent spedficd i ii jd i W. Irl L 1, pl'ans
review and/or required building it-iti o_n ll be pfl -rni by l nor c e rt_i Fied its ;mn e l 1-ridentificd in the
application. 11-ic- 1a r rcquircs i-i1 MUn1 insuran,ce requirementsfor such personnel, but. T undet-stand rh'f mav reqtlire
tix)re 111 L1. ,A11 C) protect rn,�7 interests. By exec;itting r.Ns fc r y, I ackn(-.)w1ecigc that I have made inCitilry regar iri . zhc
competence f the licensed r ceruffied personnel- and the level of therr insurancc 2nd am a n!cd that in interests are
adequately protcctedO I agree to indcmMiv, defend, and hold harniless the local government, the build-ing official, n
t i Building .for entpe.r�n _e. rare all l �m risenfrorn -��r use these licensed � erti
personntl to perforin building code inspection services with respect to the building teat is Lhe s-uhicct of the enclosed
perrrift application.
I Ltriderstand the: B�iild ig Official - .. ill eilithoritY to rcview ptans, meake requircd Inspections) Inci eliffi cc the
l a , � �, i � } r
{ .? � pursuant t� h
UI(I rds t�� -�1' �� � bv
. ` =' . , Flori t tute . T F T E e
C F � �to
Lxbsted Private
Providers o the ;ace.]
� �,� �-o-vided �r o.se
private pr �r1 3# � �v,,hall� wir1lin
business (lay after ami ch ng(� , upd this notice u
servtces provided tn'r ('11C private provideris lirriivc�d
vp IL
:o(ic, Lin , mvirol-ime-tital or orher codes,
reflect ��� :�� hate ;s. � h 1 ulldi. ; pensnsr. ��i � and/. )r .1.r1s :ti
to bUilding code cor-ij?li,,inceand o of f. eiulc rev'jew for 61.re
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JOB SITE PRIVATE PROVIDER. IDENTIFICATION FORM
Primary Contact:
EmailAddress:
Telephone Number:
Fax Number:
License Number,
Company:
Address:
Job Address:
Specific p rl't on job
site
Peri-nit Number.-
Typc of Service Being
Performed:
insurance Policy Number:
PROVIDER NO. 1
0
_& 0 0
Flonwda RrofessionaFEnorinie No., 2.)(520
283 t ECourt • uite
- -----
WestPalm Beach H�oric�a �3�
561) 686-5853
vJ
ZOO
Signed b-Y
PrjKl'der 1
Y
PrimaryContact.
Email Address:
,....,,.._.�...
Telephone Number:
Fax Nunibe.T:
License Number:
C,'ompany.
Address:
Job Address:
Spec*fie pr ject on job
PC-rmit Nu m r
Type of Service Beffig
. dorm dif
,,
Ins-urance Policy Number
PRO
i
ER NO* 2
Signed b�
Provider
�x
VIA
7 / I R
4
�.-t
•* fi�.ti� - �.�-...- -r.�.. ..-...�� ti. }M .'+r �F .M.N.. ..........i Y.S.Y...w.r. rai.� ���•
col
PC0TlClf%LAlrlM f'1C 1 IIIA011 ITv l►lt*f rM w Lijr+r
COVERAGES
CERTIFICATE NUMBER: 262832133
REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INS ' TYPE INSURANCE ADS U13
LTR : r n "A►n
GOMMERG1Ai. GENERAL LIABILITY
�!�( CLAIMS -MADE CI, 4CGi1R
GEN'L AGGREGATE LIMIT APPLIES PER.
PRO-'
POLICY JECT �I L0C
OTHER:
AUTOMOBILE OBILE LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
UMBRELLA LIAR
SCHEDULED
ALTOS
NON -OWNED
AUTOS
OCCUR
EXCESS LIAR CLAIMS -MADE
DIED I ETENTI N
WORKERS COMPENSATION
AND EMPL " LIABILITY YI N I
ANY PROPRIETOWPARTNERIEXECUTIVE
OFFICER/MEMBER EXCLUDED? N/A
(Mandatory I )
If yes, describe under
DESCRIPTION! OF OPERATIONS below
A I Professional Liability
POLICY EFF POLICY EXP
POLICY UMBERLMM/DD=![ I rk LIMITS
i �
I EACH OCCURRENCE E
DAMAGE TO RENTED
PREMISES f Ea occurrence)
IVIED EXP(Any one person)
PERSONAL& ADV INJURY I S
GENERAL AGGREGATE
PF DD T - COMP/OP AG
r
/f00 1 1101
COMBINED SINGLE LIMIT
Ea a idea t
BODILY INJURY (leer person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
` Peraccident)__
t
r
L LEACH OCCURRENCE E CE
AGGREGATE
PER OTH-
TATUTE ', � ER
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYEE!
E.L. DISEASE - POLICY LIMIT
General Aggregate
Occurrence
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Scheduler may be attached if more space is required)
Engineer.
CERTIFICATE HOLDER CANCELLATION
�o0OF O0
=00,00
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I
ACCORDANCE WITH THE POLICY PROVISIONS.
St. Lucie County
2300 Virginia Avenue AUTHORlZED REPRESENTATIVEFort Pierce FL 34962
rf��f � .2
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The AC4RD name and logo are registered marks of ACQRD
THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE
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28if Ex0hXRgje Cl,. Stc. A West Palm Beech, FL 33409 • (561) 688..2844 • CCII- (56 1) 706-2838 * Fax: (561) 686-5862
RESUME
Dom B-r,0,Djdy-n, New York 1951
Education S.S. Civil Engle
M.ffi.A., Kan-Ssdat
once
I
a
0
ring, Ransse{aer Polytechnic institute, Troy, NY (1973)
r Polytechnic Institute, Trey,. NY (1974)
� �gtrp �E,icrnal Engirreer No. 25626
L MEW"
U.
tgle 0,f �],Orjda Special Inspcctor No. 0261
(Since 1980)
:Q40324 (Since 1987)
Since 1985)
Asst Pr0j, per, T.Mojiarty & Sons Contractors, Brooklyn, NY 1974",76
Project Engineer. Robert E. Owen and Assoc-,W.Palm Beach, FL 197741
Vice President. Michael Schorah Engineers, WPalm Beach, FL 19824-87
pft$}c�e�tt, 7'hc�tr+as Twomey and Assoc., W.Palm Beach, FL 19881pPresent
100
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