2233 Seminole Rd Unit 28 - NTBOForm #9B-3.053-2002-01
Notice to Building Official of
Use of Private Provider
Effective January 20,2003
Project Name: Z/33 )P.I"'``nn le U ' T 20 co''N.1 d -eevo o I
Parcel Tax ID: 6 `I 5 1c1 0 ( 54-
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 .04-0(J WC-51§u12-e l 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: Legacy Engineering, Inc.
Private Provider: John E. Ellis III PE
Address: 6415 Greenland Road, Jacksonville, FL 32258
Telephone: 904-320-0408 Fax:
Email Address (Optional): ppidept@legacyengineering.com
Florida License, Registration or Certificate#: 81349
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.
Page 1 of 2
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 Co oration Partnership
C elto Cu;d.zrS): nC.
Print Co oration Name Print P., nership Name
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ii... ! By: By: // 1
j re) signature) 1Print
Asia,
Print Print
Name:•PlWCI k C l Asia, e, Name: QAt0. S \ o-cll.Q;C' N. •
Address:2233 $9-11.4110(Q k- Its: v i't-C P f r 5:4 s+ Its: W—
Zg Address: 2 vz E 5t . Ads ess:
TelephoneSA-. A-v. V>T•OCA F1.3202 o
No.:90 -hIZ(p'LI Y72
Telephone Telephone
No. ctoll _3$2_2Rt No.:
Please use appropriate notary block.
STATE,OF k-L
COUNTY OF DcArA k
Individual Corporation Partnership
Before me,this a t-( day of Before me,this a 1.-1 day of Before me,this day
NC)4 2(03,personally NU/ 20'd3,of 21 ,
appeared'Day,d M:tea e Luc. .e personally appeared per • ally ap•eared
who executed the foregoing instrument, QAitkS .f Kef of li li
and acknowledged before me that same Q\VA At)A.ctec ,A, ,a part n beh.
was executed for the purposes therein corp ation,on M.
expressed. behalf of the state corporation,who a p I ne,,who ! ecut d the
executed the foregoing instrument and for _oing tj trume q and
acknowledged before me that same was ac 4 owledged bef• e me that same
executed for the purposes therein w. executed for the purposes therein
expressed. expressed.
Personally known •or Produced ' • • n V Type of identification produced Di . 2.15 I i'C()Vise_
Signature of Notary Print Name
1 _b e CCA .SUM cn S
Notary Public: NOTARY STAMP BELOW
My commission expires: 05/ict 7 pMr REBECCASIMMONS
Commission#HH 131192
0 Expires May 19,2025
tf,f` " BendeQ TAn Trop F&n Ipsuronce 800485419
Page 2 of 2
Legacy Engineering, Inc.
Plan Review and Private Inspection Project Sheet
Project Address: ZZ33 Sea nct e (2-cl 0 A; 28City/Zip:MI0,4;C 136A 32Z3)County: cXAJ . l
Project Name: U i\ik 2 g 1- to le I Purchase Order#:
Client Information
Company Name: ASe Ct l u i a e t 5 ) i c\C. Company Contact: r a v ¶TSS e
Company Address: 2.12, E S*- 5}• A u'ki Si".% ne State: FL Zip: X20$0
Phone: 104 ' 219- 9 7 6 2 Cell: 10 4 -Z I a . 91 1 l Email: Pau t fir&5 e l o 5 rta.I. cowl
Invoicing Plan Review(Person responsible for Plan Review Payment) (
r
Name: Vkt) $. Fr 4-S a Email: Q a,u 14 rd-Se 1 [@ 3 /`+a:I.Car-,
Billing Address: Z( Z E 5t. City: )t. hyui-ti te.State: Ci.. Zip:3240
Invoicing Private Inspections(If same as above just write SAME)
Name: 5 a r1 t Email:
Billing Address: City: State: Zip:
Authorized Point of contact for Plan Review Communication/Permit Submission
Name: ?QV I FTh-S2. / D,k(11, S 6_0h Email: Yet-0 t-4'4-Se. tie 5 pvg,I .Co 141
Authorized Site Contacts Lit a.S 02.4 e C 6 rti
Building - Name/Cell/Email: KU k f``Se / tkUc Qt cV e / 4p¢ -211 - `I? 62/n4,/(Poe- 1 le ,ta;I,cor
Mechanical- Name/Cell/Email: LI ail t' he—r/ C(01-141- 444 /Jc roif1/4Aors Aof;dzl-a;r aC .C oM
Electrical- Name/Cell/Email: Tip 1,,c - Lt.k+- Ov1/ q p4 236/0% /TYL Erb Pre o wm w., I r e. Cow%
Plumbing - Name/Cell/Email: l fdW,5 C(a:t tj / gal- 54 J'177 I Td a,ne t, @ ait• ref
CMT - Name/Cell/Email:
1
Other—Name/Cell/Email:
Standard Terms and Conditions
All worked performed by Legacy Engineering,Inc.will be performed in accordance with Legacy's"Standard Terms and Conditions"and will be
invoiced utilizing Legacy's current standard unit rates unless noted otherwise. All invoices are due upon receipt. To assure proper report
distribution and invoicing,please provide and/or review the information requested above in detail,then sign and date the Project Set-Up Sheet and
return it to Legacy Engineering,Inc.
Acknowledgment
By signing below,the signer acknowledges they have read the"Standard Terms and Conditions"and that they have read all the information and the
information provided above is accurate and true.
Client
II I
Date:Signature: 11 74 701.g
Legacy Engineering, Inc.6415 Greenland Road,Jacksonville, FL 32258(904)-721-1100