1291-1299 Beach RES17-0311 Private Inspection City of Jacksonville—Building Inspection Division OFFIM UM ONLY
Planning and Development Department Received Date:
NOTICE TO BUILDING OFFICIAL Received By:
toR.ut,
to Quality Assurance Office
OF USE OF PRIVATE PROVIDER
PRIVATE PROVIDER CONTACT INFORMATION rSe.nda
ONTACT INFORMATION
Services to be provided: V C: fin tro❑Plan Review❑Inspections(Foundation/Slab) ❑Inspections(Above Slab)❑inspections(Mechanical) ❑11 spections(Electrical) 'p i{ . C410 ,❑Inspections(Plumbing) Zspections(Complete Permit) ��1NOTE: Private Provider to perform all impecuons in the category-1a,ted. act: ZJI — r sldai-'1n
Nameof Firm: ' iJ --_._s PffiginterineC ' nc See ,Position: J
PrimaryContact: Richard Kushner
Phone#: 904-296-0757 Phone#:
OWNER&PROJECT INFORMATION
Permit Number: `` ^ �!���3 sr� �RResidential ❑Commercial
Address: yT 11 on 17PINC A ti Ic
Property Owner: /C+ Y ^i G n 02 slndividual ❑Corporation ❑Partnership
Primary Contact: ` 1 rt Sou t , - c'r Phone#: -2 4 I — 1t 5 1
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 1 understand that I may require more insurance to protect my interests. By executing this
form, I acknowledge that 1 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.
NOTMYMTOOWNER xJ,,tt,,,� y,,,� gyp,
I attest chis i ormatlon is tr curate to the best of my Knowledge. aefare me this In day of t`xJ111�1 (T1b xo 1V—•
p Personally appeared b-ifis ctllrl I a\p S
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—� OWnef ❑Authonxed Agent Who executed the foregoing irutrument,aMaereiri edged before
propeR/Owner, Signature methesame waz ed for th Wrposes Merein expo n
T "o
1 i NMaryISignaturel:
Print Name
I 'O I ^ Printed Name: �f
(lJl g51LCPN � L01
MY Commission Ell.:
Date Commissun+F.1195a5
My(omm.Fapirzs Mayil.&19