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HomeMy WebLinkAboutNOTICE TO USE A PRIVATE PROVIDEREngineering Services, LLC Notice to Building Official of Use of Private Provider Project Name/Address: ����(?(�� �(/ Oi�T {� �1- 34 'Is 1 Parcel Tax Id: P i J a - Q00 Permit No: Services to be Provided: X Inspections _Plan Review NOTE: if the notice applies to Plan Review services the Building Official may require, at his or her discretion, the private provider also provide required building inspections pursuant to Section 553.791(2), Florida Statutes. the fee owner, affirm I have entered into'a contract with the Private Provider indicated below to conduct the services indicated above. Private provider Firm: SkyeTec Engineering Services, LLC Private Provider: Keith A. Bowman, P.E. Address: 9570 Regency Square Blvd., Ste. 410, Jacksonville, FL 32225 Telephone: 866-404-4130 Fax: 904-482-4299 Email Address: kbowman@skyeteceng.com Florida License, Registration or Certificate M PE 80568 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 off icia[ 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 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, landuse, environmental or other codes. 9570 Regency Square Blvd, Jacksonville, FL 32225 866-759-3832 www.skyetecengineering.com SkyeTec Engineering Services, LLC The following attachments are provided as required: Qualification statements and/or resumes ofthe private provider and all dulyauthorized 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 minimumof 5 years subsequent to the performance of building code inspection services. Individual (sign ureSC ) Print 6 Name: ell f�/ /i� j�4 ff,,•7 Address: 7103 .6,7 e,,d4.1 Phone: 3Cl's�y';2,f J J Please use appropriate notary block. Ft sTATEor COUNTY O — Individual Corporation Partnership Before me, thisday of Before me, this day of Before me, this day of UC— 201t 20— 20_, appeared I appeared appeared who execu dthe foregoing partner/agent an behalf of instrument, ind acknowledged of before me ti at same was executed foi the purposes a therein expr assed. A partnership, who executed the corporation, foregoing instrument and on behalf of the state corporation, acknowledged before me that who executed the foregoing instrum. same was executed for the purposes ent and acknowledged before me that therein expressed. same was executed for the purposes therein expressed. Personally k owner_ or produced identificetion�_ Type of Identification produced �r}rL\ 0C-Clt � Signs r f otary Print Name APRIL MCCLINTOCK 9570 Regency Square Blvd. Notary Public Jacksonville, FL 32225 o State of Florida 866-759-3832 www.skyetecengineering.com Comm# HH2O5833 t Expires 12/8/2025 aanoa-al.CgvtrNr I.ry3rncs:.5tteary STATE OF FLORIDA u dbpr DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION BUILDING CODE ADMINISTRATORS IS, INSPECTOR THE STANDARD INSPECTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 465, FLORIDA STATUTES BLOC MECH. ELEC FRANKLIN, KEITH DEWAYNE LICENSE NUMBER: 6N7S63 EXPIRATION DATE: NOVEMBER 30.2021 Ahasaoverify lk[.es wine at MyFi.r Ucense.com Do nos titertnis document In e" iona, r This is your Ilcense. It is unlanTW for mrone other than the licensee to use mis tlo[umerY.. STATE OF FLORIDA d bpr DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION BUILDING CODE ADMINISTRATORS & INSPECTOR T E STANOAFO INSPECTOR HEWN IS f ;FIM UNDER INE PROVISIONS OF GRAPIER 48, TLORIO.A STAI U IES PLUM.p MEOf HEINEY, RUSSELL E LICENSE NUMNEA RN3941 IXPoMl10N DATE: NOVEMEERM.Ml GW.n mn. µerne'. Wvro nl�.rilatkerv�+i E'l. Weaf lhn Xw dxum.M lnvnr Lwlr 0&eSf - n.swal'vemm lln unl.fWWlaunrwn otlNr min llM&myr:v e•e IN•_acu•ne+: F.s�iM1Qvuner Mnwaxnw. s:rtn SFATE OF FLORIDA dbpr ` DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION BUILDING CODE ADMINISTRATORS & INSPECTOR R S:ANDn DPIMsE INER RMFIN Is CmIRM'JnJ Iir PROVISIONS OF GiAPTER Oft NORIOA STATUTES llt G HEINM RUSSELL E LKFMSE NUMBER PXI2�T fSIAMTgN DATF: NOVEMHR ]0.2021 6Ymnik I-ennmlo-vs. M.lnM4'.-.x.nm C11;'yY;.O Pi+a aRnlM ¢.nwnl M aX Itl m rPPPralla llnw:.+wlJllvinwm opxlNntMlvnswlivu lMtlPaunm: Florida asvat uc�alt ©w t�Trwi w • ,....�• , Now -. .wore Doer ~' `.. wrwnr N>P .•rN�tE ie�.n�vroc Kvmmr H+yn B.Jne.+.5..+eir STATE OF FLORIDA db r DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION BUILDING CODE ADMINISTRATORS & INSPECTOR TF E STANDARD NSPFCTOR NEREc] IS COMFI£D UNDER TF E PROVISIONS OF CHAPTER 463. FIORIDA STATUTES STLITO, RALPH JCFNSF NU MEER: RWM2 EXPIRATION DATE: NOVEMRER 36.2a21 um v®ry--n,-1,m,44 Nl,l bmW mrvrm Oo nvt ;dtar :hic dv:umun, i � sry'onn lll: L• !roar Ilcen;e It h ufthw W for a -vane etlte-thD I lne lkcecee to uce thI; docdmm � ���i0'Y'"1pf tulaer aeshmv seoedn in STATEOFFLORIDA dbpr '-- DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION BUILDING CODE ADMINISTRATORS & INSPECTOR THE STANDARD INSPECTOR HEREIN IS CERTIFIED UNDER THE PROVISIONS OF CHAPTER 468. FLORIDA STATUTES WC, 182. BLDG. PLUM, MECH NAVARRO, JOHNNY ,— LICENSE NUMBERL.81 677 EXPIRATION DATE: NOVEMBER 30.2021 Always verity Ikmses online al MyFloritlalicensesom �n. 0 Do =after this Eoc .m m arty form. I" Thisisyourll"nse. Itisunlawful feranyoneotherthan the lRenseeto use this dccume . Oir Florida mm um4m 40' . N 160120-65-022A a JrE pas ♦As.A1 r07Mh, NONE r ral1w ACORDr CERTIFICATE OF LIABILITY INSURANCE lhee/ FGATE MM DDIYY Y) 1 09/28/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND 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 pollcy(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 NAMECONTACT Irene Weiss : RSC Insurance Brokerage, Inc. 1350 Avenue of the Americas 181h FlOr PHONE FAX Eat - NC. Nd E-MAILp aoDREss: iwei$s@krautergroup.com New York NY 10019 INSURER(S) AFFORDING COVERAGE NAIC.9 INSURER A: American Casualty Co of Reading PA 20427 INSURED INSURER B: Continental Casualty Company 20443 SkyeTec Engineering Services LLC INSURER C: Continental Casualty Company 20443 9570 Regency Sq. Blvd., Suite 405 INSURER D: NSURER E: Jacksonville FL 32225 INSURERF: 7ERTIFICATE NUMBER: CL2 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 VVL5UbR SO WVp POLICY NUMBER POUCYEFF MWDDIYYYY POLICY EXP MMRJDNYYY UNITS x COMMERCIALGENERALUASIUTY CLAIMS -MADE ® OCCUR EACH OCCURRENCE $ 1,000.000 PREMISES Ea Pwurmnce $ 1,000,000 MED EXP (Any on. P neml $ 10,000 PERSONAL& ACV INJURY $ 1.000,000 A 7014945225 07/15/2021 07/15/2022 GEN'LAGGREGATE UMITAPPUES PER: POLICY ❑ JECCT LOC GENERAI-AGGREGATE $ 2,000,000 PRODUCTS-COMPIOP AGG $ 2.000,000 $ OTHER: AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT Ea eccMent g 1,000,000 x BODILY INJURY (Per Penn) $ 1.000,000 A OWNED SCHEDULED AUTOS ONLY AUTOS 701510056E 07/15/2021 07/15/2022 BODILY WURY(Per accidem) $ 1,000,000 HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per awitlent $ 1,000.ODO $ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5.000,000 AGGREGATE $ 5,000,000 e EXCESS LIAB CLAIMS -MADE 7014998278 07/15/2021 07/15/2022 DED RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS'UABIUTY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? NIA PER OTH- STAME ER E.L EACH ACCIDENT $ E.L DISEASE -EA EMPLOYEE $ (Mandatory in NH) If yes, deecrm. under E.L DISEASE -POLICY UMIT $ DESCRIPTION OF OPERATIONS below C Professional Liability MCH591947545 03/16/2021 03/16/2022 Each Claim Aggregate $2,000.000 $3,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space is required) This certificate is issued as evidence of insurance coverage only. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED IN St Lucie County ACCORDANCE WITH THE POLICY PROVISIONS. Building Division AUTHORIZED REPRESENTATIVE 2300 Virginia Ave Albany FL 34982 1gRR-2n15 &CORn T1nRPORATION all rinhf,e menn•ed ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD A`oREI CERTIFICATE OF LIABILITY INSURANCE DAM(MMMDNYYY) 7127/2021 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 Marsh & McLennan, LLC 101 N Starcrest DR Clearwater FL 33765 CONTACT NAME: PHONE FAX NC No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NNC# INSURER A: QBE Insurance Corporation 39217 INSURED SKVETECE Skyetec Engineering Services LLC 9570 Regency Square Blvd Suite 405 Jacksonville FL 32225 INSURERS: INSURERC: INSURERD: INSURER E: INSURER F COVERAGES CFRTIFICATF NHIMFI 1916971696 YYIYIUCRi 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 ADOL SUBR POLICY NUMBER POLICY EFF MMIOOIYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACHOCCURRENCE $ DA AGETO PREMISES a accurrenc $ MED EXP (Any one Person) $ PERSONAL B ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY El JJEE T LOG GENERALAGGREGATE S PRODUCTS -COMPIOP AGG S IS OTHER: AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT Ea ..id $ BODILY INJURY (Per parson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per acciden0 $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLA UAB OCCUR EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE LIED RETENTION$ S A WORKERSCOMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNERIEXECUTIVE OMCERM,EMBEREXCLUDED? N/A Y QWC3001135 12/23/2020 12/23/2021 X PE OTH- STATUTE ER EL EACH ACCIDENT $1,000,000 E.L DISEASE - EA EMPLOYEE $1,000,000 (Nem1a[ary In Ni If yes, desonbe under DESCRIPTION OF OPERATIONS below EL DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS/ VERIGLES (ACORD 101, Additional Remarks Schedule, may be atdcbed it more space is required) Workers Compensation Officer Exclusion: Edwin T Nelson CEO Waiver of subrogation applies in favor of certificate holder as respects Workers Compensation only if required by written Contract, and subject to the terms, conditions and exclusions as specified in the policy. Workers Compensation states included: FL, AL, DE, GA, MD. NC, NY, SC, TN, TX, VA, HI St Lucie County Building Division 2300 Virginia Ave Albany FL 34982 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 © 1988.2015 ACORD reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD