1864 BEACHSIDE CT RES23-0065 - NTBO 10.10.23Form # ')B -•3.053-2j)02,0 ?
Notice to Building Official of
USe of Priv--rte Provider
EffecEjve JaauAry 20, 200,3
f`rnjed Name:
Parcel Tax ID.
Services to be provided. i'lans Review
Inspections ��
Note- If (11c notice applies IQ either private plan review or private inspection ser%, ices the Building
Ofticiaf rimy require, ai his or her discretion, the private providcr be used fur both services pur
Section 553.791(2) Florida Statute, srran# to
S
owner. affirm I have crtirred into a contract with the Private provider indicated below to conduct the Crvicthe
fee
indicated above.
Private Provider Firm -
[a
Pril'ate Provider'
Address: 5—LiI1MV'a-
2*m .
Fax -
Email Address (Op ional),
Florida License. Registmion or Certificate to 0:
1 have elected to use erne or metre private providers to provide budding code purrs review and/or jnspecxion
services on the building that is tyre srtbjec:t of the enclosed perrr I application, "authori74d by s, 553.71)1, FIPHda
Statutes. 1 understand that the local building official may notre view the plans submitted or perform the required
building inspections to determine compliance wiIII the applicable codes, except to the extent specified in said Inv.,
Instead, plans review and/or required buiidinV inspections will be performed by licensed car cerdtied personnel
identified in the application. The law requires �ni.ni=rn insurance requirements for such personnel, but 1
understand that I may require rnnre insurance to protect my interests. ley executing this form, 1 acknavc�Wge that t
have made inquiry regarding the ccrnpeience of the licensed or certified personnel and the level of their insurance
and am satisfled that my Interests are adequately protected. f agree to indemnity, de Fend, and hold harm Iess the
local goverment, the local building official, and their building code enforcement personnel from any and ail
claims arising From my use of these licensed or certified personnel to perform building code inspection ser'<+iccs
+rritl7 respect to the building that is the subject of the enclosed permit application.
1 understand ire Building Official retains authority to review plans, make required inspections, and enforce the
appIicabIc codes within his or her charge pursuant to die stacndarcis established by s, 553.791. F Imide Statutes. If I
make any changes to the listen private providers or the services to be provided by torose private providers, f simll,
within I business day after any charge, update this notice to reflect such changes. The buil€3ing plans review
andlor inspection services provided by the private provider is limited to building rode c'ompl iance and dens not
include review for lire code, Iand use, environmental or outer codes.
Page 1 of
Tie l llok ing artachrne,% are A vid as
rcq�i.
! !,I,ifical
",slatement,� -W&or resumeafinsurarrce for of the
occurrence pr #`essional and eom Fivate prop ider and all dul
daring to all SCrvices Arch "Isive liabiii[ in
tie Y authorized re
or 5 years stlb'eq uetrl to rhe perf`crntedamount o!` Presetttaii►�e
Per#orrnar�ce oFhuildanrate m► rder, irtc[trdin # l miflior� per
Jndi4:dusi � code lr#5 �' fa3] eovc`Fage dot a
Rection Vices, minimum
Printsignature)
Name- CrAddrew;
Telephone, —see,�.r 1 3
'lease use appropriate natan brvck
TATE OF
`OUNTY OF
Idividual
efore me, this day of
ICIT, ?0— pef%iDnally
tpeared
ho executed the foregoing instrumenl,
Id =knawjcdgcd Wore me that same
31 executed for the purposc5 therein
;presscd.
f 'v *
ML
Mr"O"Ul r ,
Iorporat on
Fr- �nr tura ions
13Y
Print (s{g"tura]
Name:
Its,
Address:
TeIePhone
No -
a rpa ratWn
Before me. Lhis day of
Krsunafly appe4ted —
�f
_ eorparatioa, OFT
behalf -of the stat€ corporation, wlx,)
executed the foregoing instruratmt and
acknowledged before me that same was
e eculed for the purposes thrrcin
exOTT sed.
Partnership
i'rinl t'�et liip
is
Printneturc)
Name:
Its:
Ad$resg; �
Tefcphvpje
No.,
Parreership
Before me. this day
Of— , 2p—
trersonally appeari5d i
pportncrraseal on behairof
a parlarm yip. who executed the
foregoine, instrurnrnt and
acknowledged before me that same
wo executed For the purposes therein
expressed,
,rsonally known ; or Produced identiticztion _ l'wpe of idc�ttilication used
Print NwTw�A&9�NA�
gmiure of A OWY
nwn Pubhr.= NOTARY STAMP BOLO
commissW expires,
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