1853 Selva Grande Drive POOL24-0010 NTBOForm 913-3.053-2002-01
Notice to Building Official of
Use of Private Provider
Effective January 20, 2003
Project Name:
Parcel Tax ID: )lp9592 - 3..)28
Services to be provided:Plans Review Qas insp. NOT included
Note: If the notice applies to either private plan review or pri e 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.
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:Le ac En ineerin Inc.
John E. Ellis Ill PEPrivate Provider
6415 Greenland Road Jacksonville FL 32258Address:
Fax:Telephone: 904-320-0408
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 Ihave made inquiry regarding the competence of the licensed or certified personnel and the level of their insuranceand am satisfied that my interests are adequately protected. I agree to indemnify, defend, and hold harmless thelocal government, the local building official, and their building code enforcement personnel from any and allclaims arising from my use of these licensed or certified personnel to perform building code inspection serviceswith respect to the building that is the Subject of the enclosed permit application.
I understand the Building Official retains authority to•review plans,nake required inspections, and enforce theapplicable codes within his or her charge pursuantto' th&standards established by s. 553.791, Florida Statutes. If Imake any changes to the listed private providers or the services to be provided by those private providers, I shall,within I business day after any change, update this notice to reflect such changes. The building plans reviewand/or inspection services provided by the private provider is limited to building code compliance and does notinclude review for fire code, land use, environmental or other codes.
Page I of 2
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
12
(signarint D
d res :
Tele one
No.
m4 A-Dr,52
Please use appropriate notary block.
STATE OF Onda
COUNTY OF
Individual
B e me, this day of
, 20 , person lly
appeared
who execute the foregoing instrumeand acknowledged before me that samewas executed for the purposes thereinexpressed.
Corporation
Print Corporation Name
By:
(signature)
Print
Name:
Its:
Address:
Telephone
No.
Corporation
Before me, this
personally appeared
day of
20
of
acorporation, onbehalf of the state corporation, who
executed the foregoing instrument andacknowledged before me that same wasexecuted for the purposes therein
expressed.
Personally known , or Produced identification _l_Type of identification produced
Signature of Nota \Print Name
Partnership
Print Partnership Name
By:
(signature)
Print
Name:
Its:
Address:
Telephone
No.:
Partnership
Before me, this dayof, 20personally appeared
partner/agent on behalf of
a partnership, who executed theforegoing instrument andacknowledged before me that samewas executed for the purposes thereinexpressed.
h rli
Notary Public: NOTARY STAMP BELOW
My commission expires:jl-D-Z7 DEBORÆ{ WERLINGMY COMMISSION HH 422502EXPIRES: Novenber 17, 2027