1850 Francis Ave RES23-0251 - Legacy Notice to Building OfficialForm # 9B-3.053-2002-01
Notice to Building Official of
Use of Private Provider
Effective January 20, 2003
Project Name: Mack -Moore Window and Doors
Parcel Tax ID: 172125-0025
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.
I January Mack Moore 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.
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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
Jan ry Mk -Moore (Jan 16, 202415:42 EST)
(signature)
Print
Name: January Mack Moore
Address:1850 Francis Avenue
Atlantic Beach, Fla 32233
Telephone
No.: 904-962-6122
Please use appropriate notary block.
STATE OF Florida
COUNTY OF Duval
Individual
Before me, this IU day of
January , 20 24_, personally
appeared January Mack Moore
who executed the foregoing instrument,
and acknowledged before me that same
was executed for the purposes therein
expressed.
Corporation Partnership
Print Corporation Name Print Partnership Name
By:
By:
(signature)
(signature)
Print
Print
Name:
Name:
Its:
Its:
Address:
Address:
Telephone
Telephone
No.
No.:
Corporation
Partnership
Before me, this day of
Before me, this day
20_,
of 20_,
personally appeared
personally appeared
of
,a
partner/agent on behalf of
corporation, on
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 ; or Produced identification X Type of identification produced Driver's License
Signature of Notaryy ` 1
Not Public• NOTARY STAMP BELOW
—j
My commission expires: 05/27/2027
Print Name Barbara L Gudith Petit
Notary Public State of j
1 Barbara 1. Gudith Pll') My Commission HH 3Expires 5127t202
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