857 BONITA RD NTB UNIVERSAL ENGINEERING SCIENCE, INC.
r 5561 Florida Mining Blvd P
6\4Jacksonville, FL 32257
904-296-0757 — Fax: 904-296-0748 11641
NOTICE TO BUILDING OFFICIAL—USE OF PRIVATE PROVIDER
Project Name: Dunn-Garage Plans Review Inspections Both
Parcel Tax I.D 171150-0000 Circle one
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 to be used for both services pursuant to Section 553.791(2)Florida Statute.
Dan Dunn
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:Universal Engineering Sciences,Inc. FL.License,Registration or Certificate No. P.E. 38705
Private Provider: Richard G. Kushner, P.E.
Address: 5561 Florida Mining Blvd,Jacksonville, FL 32251 Phone: 904-296-0757 Fax: 904-296-0748
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.
INDIVIDUAL CORPORATION PARTNERSHIP
Print Individual Name Print Corporation Name Print Partnership Name
By: �—(• By: By:
(signature) (signature) (signature)
Print Print Print
Name: Dan Dunn,property owner Name: Name:
Its: Its:
Address: 857 Bonita Road,Atlantic Beach,Flonda,32233 Address: Address:
Telephone Telephone Telephone
No: 619 994-2754 No.: No.:
Please use appropriate notary block.
STATE OF FLORIDA
COUNTY OF DUVAL
Individual Corporation Partnership
Before me,this 18th. day of Before me,this . day of Before me,this day of
April ,20 22 ,20 , a ,20
personally appeared who executed the foregoing Corporation,on behalf of the state personally appeared Partner/agent on
instrument,and acknowledged before me that corporation who executed the foregoing behalf of, a partnership,
same was executed for the purposes therein instrument,and acknowledged before me who executed the foregoing instrument,
expressed. that same was executed for the purposes and acknowledged before me that same
therein expressed. was executed for the purposes therein
expressed.
P0/ ,or,produced identification Type of identification produced PHYSICALLY PRESENT
Quin J Hagerty
ignat.l • • N. ary Print Name
Nota P li • .-V cTAnAr'nr- My commission expires:
"1„ OWN J. HAGERTY
ja. '' '\Notary Public-State of Florida
11.1 •= Commission N HH 105930
'r•`r My Commission Expires
��'•irn�'�
Juno 26, 2025
I p UNIVERSAL ENGINEERING SCIENCE, INC.
5561 Florida Mining Blvd
Jacksonville, FL 32257
904-296-0757 Fax: 904-296-0748 164
NOTICE TO BUILDING OFFICIAL—USE OF PRIVATE PROVIDER
Project Name: Dunn-Garage Plans Review Inspections Both
Parcel Tax I.D 171150-0000 Circle one
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 to be used for both services pursuant to Section 553.791(2)Florida Statute.
Quin J.Hagerty,President,Hagerty Construction&Roofing, Inc.
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:Universal Engineering Sciences, Inc. FL. License,Registration or Certificate No. P.E. 38705
Private Provider: Richard G. Kushner,P.E.
Address: 5561 Florida Mininq Blvd,Jacksonville, FL 32251 Phone: 904-296-0757 Fax:904-296-0748
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.
INDIVIDUAL .. •1RPORATION PARTNERSHIP
Print Individual Name Prin pl.s Name Print Partnership Name
By: (By: By:
(signature) gnature) (signature)
Print Print Print
Name: Name: Quin J -gertY Name:
Its: 12850 VSnthrop Cove Drive Its:
Address: Address: Jacksonville,Florida.32224 Address:
Telephone Telephone 904-992-9960
Telephone
No: No.: No.:
Please use appropriate notary block.
STATE OF FLORIDA
COUNTY OF DUVAL
Individual Corporation Partnership
Before me,this day of Before me,this 18th day of Before me.this day of
20 April ,20 22 ,a ,20
personally appeared who executed the foregoing Corporation,on behalf of the state personally appeared Partner/agent on
instrument,and acknowledged before me that corporation who executed the foregoing behalf of, a partnership,
same was executed for the purposes therein instrument,and acknowledged before me who executed the foregoing instrument,
expressed. that same was executed for the purposes and acknowledged before me that same
therein expressed. was executed for the purposes therein
expressed.
Personally known or,produced identification Type of identificatiproduced PHYSICALLY PRESENT
Tiffany Sral X ^ ! �yA. Q
Signature of Notary Print Name
Notary Public: NOTARY STAMP BELOW My commission expires:
Y°ii'',. TIFFANY GARDNER SRA_
Notary Public-State of Florida
0,?j Commission#HH 041479
.,pfn,;. My Comm.Expires Sep 10,2024 F
Bonded through National Notary Assn. I
____ 4