HomeMy WebLinkAboutNOTICE OF USE FOR PRIVATE PROVIDERNotice to Building Official of
Use of Private Provider
SCNNEL .
Project Name: Wawa (FLO) St
Parcel Tax ID: 3419-540-0055-000-4
Services to be provided: Plans Review F-1 Inspections IV-1
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.
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: ATC Group Services LLC
Private Provider: Alexis E. Paniagua, PE
Address: 9955 NW 116 Way, Suite 1, Medley, FL 33178
Telephone: Fax 51" fMV
Email Address (Optional): alexis.paniagua@atcassociates.com
Florida License, Registration or Certificate #: 62519
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 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, land use, environmental or other
codes.
1 of 2
The following attachments are provide 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
Corporation
Partnership
ATC Group Services LLC
Print Corporation Name Print Panne ti •cnr
By: By:
(signature) (signature) a re
Print Print Print
Name: Name: Name: Alexis E. Paniagua, PE
Address: Its: Its: Branch Manager ee
Address: Address: 9955 NW 116 Way
Telephone Medley, FL 33178
Please use appropriate notary block.
STATE OF & j("-j'
COUNTYOF I�9'r,ti—
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.
Telephone Telephone
No. No.:305-882-8200 ee
Corporation
Before me, this day of
,20�
personally appeared
of
corporation, 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
Bpfale me, this 19 day
o , 20-LZ ersonally
ap Wed i '- �' • U �.
partner/agent on behalf of
partnership, who executed the
foregoing instrument and acknowledged
before me that same was executed for
the purposes therein expressed.
Personally kno` � f . • qr fofcjdced identification _Type of identification produced
r�ti�%bay
Signature 6 Print Name
Notary Public: NOT STAMP BELOW
My commissiol(tWjnjlffii"' (—/f-;W 0
P�xtY 19,
�•o N•*= 2 oft
MFF93MI i�Q
Notice to Building Official of
Use of Private Provider
jGANNED
Project Name: Wawa (FLO) AV
�
Parcel Tax ID: 3419-540-0055-000-4 LucieCOUP1py
Services to be provided: Plans Review Inspections ✓�
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,
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: ATC Group Services LLC
Private Provider: Alexis E. Paniagua, PE
Address:
Telephone:
9955 NW 116 Way, Suite 1, Medley, FL 33178
Fax:
305-882-1200
Email Address (Optional): alexis.paniagua@atcassociates.com
Florida License, Registration or Certificate #: 62519
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 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, land use, environmental or other
codes.
1 of 2
The following attachments are provide 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 apprro/oy,Priate notary block.
STATE OF _ — ZJ: j1 -
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
Print Corporation Name
MA
(signature)
Print
Name:
Its:
Address:
Telephone
Corporation
Partnership
ATC Group Services LLC
Print Partner ip e
By:
e)
Print
Name: Alexis E. Paniagua, PE
Its: Branch Manager o
Address: 9955 NW 116 Way
Medley, FL 33178
Telephone
No.:305-882-8200 ee
Before me, this day of
, 20�
personally appeared
of
corporation, 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
Befpremp, this / / day
of 20J '7 personally
appeared �7�s
partner/agent on ehalf of
a partnership, who executed the
foregoing instrument and acknowledged
before me that same was executed for
the purposes therein expressed.
identification _Type of identification produced
Print Name
Not 1cc: NC Y STAMP BELOW
My commisRlptlltN
2 of
CFF935nj ?�Q
1 4
Notice to Building Official of
Use of Private Provider
Project Name: Wawa
Parcel Tax ID: 3419-540-0055-000-4
Services to be provided: Plans Review El Inspections Iy l
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
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: ATC Group Services LLC
Private Provider: Alexis E.
Address: 9955 NW 116 UI
Telephone:
305-882-8200
PE
Suite 1, Medley, FL 33178
Fax: 305-882-1200
Email Address (Optional): alexis.paniagua@atcassociates.com
Florida License, Registration or Certificate #:
62519
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 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, land use environmental or other
codes. c`
• � 1.
1 of 2
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