760 Paradise Ln Notice to Building Official '.. TANNED
mate: 5VPA
Form #9B-3.053-2002-01
Notice to Building Official of
Use of Private Provider
Effective January 20,2003
ProjectName: ;�• ,�c Z, r�?��� �i ��ts����
Parcel Tax ID: 1-1 2 37<o
Services to be provided: Plans Review Inspections X
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. 1
I -ZI *--\3 v���-��J t 5 �%, e r L1-c the fee
owner, affirm I have entered into a contra t with the Private Provider indicated below to conduct the services
indicated above.
Private Provider Firm; Universal Engineering Sciences
Private Provider: Richard G.Kushner
Address: 5561 Florida Mining Blvd.Jacksonville,FL
Telephone: 904-296-0757 Fax:
Email Address(Optional): jaxppi@universalengineering.com
Florida License, Registration or Certificate#: FLPE 38705
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.
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The following attachments are provided 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 Corpora ' n Partnership
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to
ration Print Partnership Name
By. By:
(signature) (signature) (signature)
Print PrintPrint
Name: Name: a 1 u � s Name:
Address: Its: M f.no 4.r Its:
Address: Address:
Telephone a 1 —Zr.-5-
No.
Telephone Telephone
No. y CH (oI� Dz-1 $ No.:
Please use appropriate notary block.
STATE OF
COUNTY OF
Individual Corporation Partnership
Before me,this day of Before me,this 1'5", day of Before me,this day
20_,personally M a ,201±nj of ,20_,
appeared pqrsonaft a peared personally appeared
who executed the foregoing instrument, u of
and acknowledged before me that same LLL- a partner/agent on behalf of
was executed for the purposes therein 6 corporation,on
expressed. 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 ;o oduced identifi n Type of identification produced F lAJ
Print Name � " U n Signature of NotaryV ��� � ��C(..��
Notary Public:NOTARY STAMP BELOW ill CHRISTIANAV O'CONNOR
v k, Notary Public-State of Florida
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,{l` •= Commission#GG 177533
au� , My Comm.Expires Jan 22,2022
My commission expires: L Z '�'� "e' yondod through National Notary Assn.
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