1927 Beach Ave RES18-0010 Private Inspector City of Jacksonville—Building Inspection Division
OFFICIAL USE ONJY
Planning and Development Department Received Date:
NOTICE TO BUILDING OFFICIAL Received By:
OF USE OF PRIVATE PROVIDER Route to Quality Assurance Office
PRIVATE PROVIDER CONTACT INFORMATION CONTRACTOR CONTACT INFORMATION
Services to be provided: r---
❑ Plan Review Primary Contact: 5-62r J -Y ' __S-
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❑ Inspections(Foundation/Slab) alinspections(Above Slab) 67oi, f n �Z
Position:
EfInspections(Mechanical) RInspections(Electrical) QQ
® Inspections(Plumbing) (KInspections(Complete Permit) Phone#:
NOTE: Private Provider to perform all inspections in the category selected.
Secondary Contact:
Name of Firm: Universal Engineering Sciences
Primary Contact: Richard Kushner Position:
Phone#: 904-296-0757 Phone#:
OWNER&PROJECT INFORMATION
Permit Number:! s��_QO/0 wry ., *Residential ❑Commercial
�
Address:
Property Owner: Tl 0C.t/ Individual ❑Corporation E3 Partnership
PrimaryContact: c0�/ ��v�S Phone#: 907 S7) �� 000/Z
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.
NOTARY AS TO OWNER
I attest this information is true accurate to the best of my Knowledge. Before me this�_day of 20
20
Personally appeared 1►I I C�� �� JC "'s
'Property Owner Signature ❑ Owner IN Authorized Agent Who executed the foregoing instrument,and acknowledged before
_ me the same was executed for the purposes therein expressed.
-� Type of ID produced: �o S
rint Name Notary(Signature):
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A".
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Printed Names;.yk.; ENID V.JOHNSON
Date My commission
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"�•R;k° 'Bonded ilr Troy Fain Insurance 800-3857019