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HomeMy WebLinkAboutNOTICE FOR PRIVATE PROVIDERivcsveo pp(t1%TO OQPpC�`od ?elm ���u e cper Form # 9B-3.053-2002-01 Notice to Building Official of Use of Private Provider Effective January 20, 2003 GYa3—� 56 J� SCANNED BY St. Lucie County Project Name: OCERW/c$t.1V, or-e&-n%G401V7 Gonl D0 00Lv5/2'/ Parcel Tax ID: 3 — 5 OG � cP00 0 — 400 O — e�> 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. 505Z('. owner, affirm I have entered into a indicated above. ,3 gc with the Pi 13 OF /J To/ZS the fee Provider indicated below to conduct the services Private Provider Firm G 5M Al- G ?9"' C&9 270SV Private Provider. Address: A 8 s w `'��gry �'� v O, s -r a"9AT. a 3947Yy4 Telephone: ?7a' A-2Fax: Email Address (Optional): LF% i0%�2D �N (�� C 5m-- B , A11C Florida License, Registration or Certificate #: 76 `%/PJ I have elected to use one or more private providers to provide building code plans review and/or inspection services on the budding that is the subject of the enclosed permit application, as authorized by s. 553.791, Florida Statutes. I understand that the local budding 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 budding 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 budding code compliance and does not include review for fire code, land use, environmental or other codes. Page 1 of 2 The following attachments are provided as required: Rereviev pQR 121p1e2. P of ofQualification insurance for profes ional andresumes compehensi e provider liability in then mount o $1 authorized pepa`�`�.purrence relating to all services performed as a private provider, including tail coverage for a minimum ,,vO' �u e�0of5 years subsequent to the performance of building code inspection services. Indioi: du al (signature) Print Name: Address: Telephone Please use appropriate notary Mock. STATE OF TG Q nn COUNTY OF � 1,U C1-Q 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 Partnership c9c,EF)n� dry evNOAss✓ 11P��rint m on Na Print Partnership Name / V. By: (signature) (signature) Print Name: 4-0:e' Pif /f9/ldly Name: Its: Its: Address: 'f'/ 8o Address: �mrat Ptc:r•CL, �r� 3�9�9 Telephone No. Corporation i Be re me, this day of personally appeared SOSFz1911/f 9 e_p�of rj D GG/J-n/i 4 4 CO n/lld rf' . a odd ' &VWAZO lF rporation, on behalf ofthe state corporation,who executed the foregoing instrument and acknowledged before me that same was executed for thepurposes therein expressed. Telephone Partnership Before rare, this day of 20_, personally appeared partner/agent on behalf of a partnership, who executed the foregoing instrument and acknowledged before me that same was executed for thepurposes therein expressed. Personallyknown_;or Produced identification Type of identification produced jrLot' Signature of Notaryy za./ Print Name jZOscFC JN`VW Notary Public: NOTAAI;yjrSTAMP BELOW, 0 My commission expires: Ea A05AIDA NIVAN Natary Ptsblic—State ofFlorida CommissionYGG099707 . MyComm, Expires May 1, 3021 Page 2 of 2 • Vi CENED APR1%10 pern�ittin9 , c'unt ant 5[. Luclcounty Licensee Details Licensee Information Name: Main Address: County: License Mailing: LicenseLocation: License Information License Type: Rank: License Number: Status: Licensure Date: Expires: DARDEN, CHARLES ALBERT ]R (Primary Name) 1812 S.E. ELROSE STREET PORT ST LUCIE Florida 34952 ST. LUCIE Professional Engineer Prof Engineer 76910 Current,Active 01/17/2014 02/28/2021 4:59:01 PM 4/112019 }Ron DeSantls Governor - FBPE` 'FLORIDA'BOARD,OF ,S I A I'E OF F1O RI,D/"� , PROFESSIONAL ENGINEERS' BOARD OF PROFESSIONAL'ENGINEERS . ' THE'ENGIN.EERINGBUSIN�ES ,HERE}_ S�AiU,T�HORIZEDUNDER -THE PROVISIO CF CRARTERt47;1, FLORIDA�?S`fATUTES` CSM �'IfE�NG N ERL�a --ULC �20lk 8�(S�W,,C)CE�ANpBLVD I ART F,1? 9.94r LICEf\1SE NUMBER: CA29057:'' , _EXPIRATION DATE: FEBRUARY 28, 2021 :. Always yen ify`licenses online.at MyFloridaLlcense.com Do,not alterkfils document in any form. ? .This is your` licenseAt is unlawful for anyone other than th'e licensee•to use this document. c r'-m�7i�by� G✓ —r-:2' L 9 eo /0 ,.cl b / , RMFNGI-02 BRROWN 4111 CERTIFICATE OF LIABILITY INSURANCE DA E(MWD IY Yn 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(les) must have ADDITIONAL INSURED provisions or he 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 CONTAMEACT Barbie Brown - Ext. 237 R V Johnson Agency, Inc. 2041 SE Ocean Blvd y Stuart, FL 34996 aCo,NN&E:e: 772) 287-3366 ac, No:(772) 287-4255 E.MA' . bbrown@rvjohnson.com INSURERS AFFORDING COVERAGE NAIC A INSURERA:OId Dominion Insurance Co. 40231 INSURED INSURER 9 : Travelers - FWCJUA INSURER C :StarStone National Ins Co. Harborside Financial Ctr CSM Engineering, LLC I INSURER 0: 208 SW Ocean Blvd Stuart, FL 34994 INSURER E: INSURER F : COVERAGES CERTIFICATE NUMRER- 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 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 TYPE OF INS ADDLSUBR POLICY NUMBER POLLTR ICY EFF POUCYEXP LIMITS A X COMMERCIAL GENERALUABIU7Y CLAIMS -MADE QX OCCUR BPG7789D 8/2512018 8125/2019 EACHOCCURRENCE S 1,000,000 DAMAGE TO RENTED $ 600,000 MED EXP oneperson) S 5,000 PERSONAL a AOV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY ❑ Yp&- LOC OTHER: GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMP/OP AGG $ 2,000,000 S A AUTOMOBILE LIABILITY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS Ep AUTOS ONLY X AN,ONLY BPG7789D 8125/2018 812512019 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Par cement S BODILY INJURY Par accident S HANY P�OPPERdo^DAMAGE $ UMBRELLA UAB EXCESS UAB OCCUR CLAIMS -MADE I I EACH OCCURRENCE S AGGREGATE S DED I I RETENTIONS S B WORKERS COMPENSATION ANDEMPLOYERTLUIBIUTY YIN ANY PROPRIETOR(PARTNERIEXECUTIVE OFFICERIMENgER EXCLUDED? ❑N LMandatoryiIt NH) If yes, descr,De under DESCRIPTION OF OPERATIONS bar" NIA 6FR13UB-SG45415.5-18 4/512018 41512019 X PER OTH- E.L. EACH ACCIDENT S 500,000 E.L DISEASE - EA EMPLOYEE S 500,000 Er L DISEASE -POLICY LIMIT 500,000 $ C Professional Errors 21560E182APL 4124/2018 4124/201 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached If mom space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE For Insurance Purposes Only P Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD