HomeMy WebLinkAboutNOTICE USE OF PRIVATE PROVIDERThe following attachments are provide as required:
1. Qualification statements and/or .resumes of the private provider and all :duty authorized
representatives.
2. -Proof of insurance- -for prollmisional and comprehensive liability in the amount of $4 millioft per
occurrence relating to all services .performed as a private provider; including tail coverage for a
,minirrlurn:of 5 year's subsequant:to the.,perfor.m. ance of building todejnspectj,qp serylices.
Individual
(signature).
Prfilt
Name:
Address:
Telephone
f1easemse Approptiate notaryblocU.
STATE OF
COUNTY OF
Individual
Before me, this day of
-20,
appeared
who executed the foregoing instrument,,,
aril *knowledged bcf)re rite itt.4- same
was executed for the purposes therein
expfessed.
Corporation ,
�4?4ecl'a' i)
Print Corpotatioix Ntung.
By:
PHIlt (S�Wrature)
Ntarne-, IDeoLs G
Its:-
A A
Addre
MIA,
960—a 7441v�i3z
Telep'hz
No. N
corpdrat.ion
Before.me,this, day of
personally appegread
L07 � VA"45 -of
Pair.tnership
Print Partnership Name
By:
Print
Name: am
Its:
Address, --
Telephone
.No.-
corporation, Qn-
behalf of the state corporation, who
executed:l�e:fbregoiiig instrument and
acknowledged before me that same was
executed f6r the purposes therein
expressed;:
Partnersl4p.
Before me, this day
of 211 personally -
appeared
partndr/agent on behalf of
a partnership, who executed the
forego
ing ent and Acknowledged
before me that san, ie was e.vauted for
the purposes therein expressed.
OTI?. en I PersowMly known todnw ed 'd tificam on Type of identifictftion produced,
SigA re of Notary Print Name
Notary Public: N1. OTARY'STA,\4P BELOW
N/ty commission expires-.
KIM A. NOTORIS
Notary PublicState of Florida
Commission # GG 096212
My Comm. Expires May 9,2021
2 of 2
gwded thfougmtalonal Notary kssf,