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HomeMy WebLinkAboutAPPROVED Private Provide informationNotice to Building Official Of Use Of Private Provider ProjectNarne: Ken and Cathleen Saunders Parcel Tax ID 4502-803-0038-000-3 Services to be provided: Plan Review Permit Number Tnspections INSPECTIONS Note: If the notice applies to either private plan reviev, or private inspection services the Buildling Official may requires, at his or her discretion, the private provider be used for both services pursuant to Section 553.791 (2) Florida Statute. I Ken Saunders the fee owner, affirm 1. have entered into a contract with the Private Provider indicated below to conduct the. service.-, indicated above. Private Provider Firrn: Thomas J. Twomey PE Private Provider Thomas J. Twomey I ' -aN: Address: 2831 Exchange Court, Suite A West Palm Beach, FL 33409 Telephone: 561-686-5853 Cell Email twomeyengineering@yahoo.com Florida License, Registration or Certificate #: 25626 Thave 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,Yi'lorida 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 ond/or required building inspections will be performed by .licensed or certified personnel inderitified in the application. The law requires minimum insurance requirements for such personnel, but I understand that I may require more insurance to protect iny 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 building official, and their building code eriForcement 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, f shall, within I business day after any change, update this notice to reflect such changes. 'T'he 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, envirownent-al or other codes. ' r` 1 ►' 1 E _.__._._ Prirrzary Contaet: _ fznaii Address: `T --fr„i o t✓1 elephone i`+ rnber: Fax Number. License Number: Company: i e _— Address: Est I'altn �e3�h rt a _.._. Job Address: �pecitic project ozz job site: Permit Number: Type of Service Being _.__..._... Perfonned: Insurance :Policy Number: --- -- Signed by .� er � l� Y PRO DER. No. z Pl'riilal'y C;OntaCt: � _-------------j I Email Address: Telephone Number: Fax Number: License Number: _ Company: Address: Job Address: - ---- Specific project on job srie: Permit Number: Type of Service Being Pei -formed: Tusurance .Policy Number: _......................... Signed by Provider Ozi The following attachments are provided as required: 1. Qualification statements and/or resumes of the private provider and all duty authorized representatives. 2. Proof of insurance for professional and comprehensive liability in the amount of $1 million per occurrence relating to all services performed as a private provider, including tail coverage for a minimum of 5 years subsequent to the performance of building code inspection services. Corporation Print Corporation Name By: (signature) 41ri Print Nalj,e�:iA6M A- S J. TWOMEY, P.E. Name: Ad . 11eirida Professional En ineer No. 25626 its: I C . 983LJixchangi_-_CcLurt -Suite A AdTress: Telepho Vest ValmBeach, Florida 33409 No.:- __(561)_686-5853 Telephone 'p ')` No. Please use appropriate notary block. STATE OF IS f-A(4 C COUNTY OF 2z.( vv-', _T>C'C� 4 Individual Before me, this day of n Ly-\e 20_��A,. personally appeared who exccuted the foregoing instrument, and acknowledged before me that same was executed for the purposes therein expressed. Partnership Print Partnership Name By: (signature) Print Name: .Its: ----- Address: Telephone No.: Corporation Partnership Before me, this day of Before me, this day 20_ of 20___, personally appeared personally appeared of , a partner/agent on behalf of corporation, on behalf of the state corporation, who a partnership, who executed the executed the foregoing instrument and foregoing instrument and acknowledged before me that same was acknowledged before me that same executed for the purposes therein was executed for the purposes therein expressed. expressed. Personally known ca'or" Produced identification = Type of identification produced Signature of Not Lryj'//� l 11rintName I A, N5417�,Z Notary Public: NOTARY STAMP BELOW My commission expires: aar � I 'ct"y Public S Jennifer M Ashby of FlOnda My COM, 'B$#On HH 001',,05 Expires 101211202,. Page 2 o 4.'2 2831 BXCUR990., Ste, A PVftst Palm Beach. 12133409 - (561) 688-2844 - Cc) 1- (561) 706-2838, Fox - (561)686­5862 RESUME Qtsan Brooklyn, New York 1951 Education B.S. Civil Engineeriy1g, Rensselaer Polytechnic Institute, Troy, NY (1973) M.B.A., Rensselaer Polytechnic institute, Troy, NY (1974) SU" OofMiona'l Ensincer No. 25626 (Since 1990) 40324 (Since 1987) Inc tMe Of Florida Special Inspector No, 0281 (Since 1985) 9 Of Special Inspector N=0281 �(Sin�c ExpWience Aissit Prof. Mr. T.Metarty & Sons,Contractors, Brooklyn, NY 1974-76 Project Engineer. Robert E. Owen and Assoc.,W.Palm Beach, FL 1977.81 Vice President. Michael Schorah Engineers, W. Palm Beach, FL 1982-87 Ntsident. Thcmas Twomey and Assoc., W.Palm Beach, FL 1998-Presen't I -0 —� VVINDDOG-02 EDENL DAT/2212D/Y 1 122/2021 ,d► Ro CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER License # OE67768 Insurance Office of America Abacoa Town Center 1200 University Blvd, Suite 200 Jupiter, FL 33458 CONTACT Dianne Klaus NAMP PHONE FAX (AIC, No, Et):(561) 721-3746 (Arc, No): AE-MAIL Dian ne.Klaus ioausa.com DDRESS: INSURERS AFFORDING COVERAGE NAIC # INSURER A: Southern -Owners Insurance Company 10190 INSURED INSURER B: American Builders Insurance Company 11240 Window Doctor Glass and Glazing Contractors, Inc 1133 Old Dixie Hwy Suite 7-8 INSURER C : Lake Park, FL 33403 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATF NIJMRFR• REVlclnnl nU InnRl=a• 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 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 7 OCCUR 72255641 1/31/2021 1/31/2022 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISESEa occurrence 300,000 $ MED EXP (Any oneperson) $ 10,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L X AGGREGATE LIMIT APPLIES PER: POLICY PRO-- LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 $ Included AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accdent $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 4225564101 1/31/2021 1/31/2022 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X I RETENTION $ 10,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WCV 0253987 03 2/1/2021 2/1/2022 �( PER OTH- E.L. EACH ACCIDENT 500,000 $ E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT 500,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE St. Lucie County- Contractor Licensing 2300 Virginia Avenue ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD