310 Camelia St RESO21-0025 Notice to Building Official di�h �l -- NL-----
CITY OF ATLANTIC BEACH OFFICIAL USE ONLY
TiV NOTICE TO BUILDING OFFICIAL
'�' ) OF USE OF PRIVATE PROVIDER Received Date:
0 iiirespizi
Received By:
lot r j t..)�
PRIVATE PROVIDER CONTACT INFORMATION CONTRACTOR CONTACT INFORMATION
Services to be provided: I ,
�� Primary Contactt:pRI Ilp `Ro 1j
Plan Review I/x Inspections(Re-Roof)
Position: ftCtlY2- L Q VvY1�
Inspections(Foundation/Slab) Inspections (Other) 111
Phone#: G(4-�4[Q-%0 1
Inspections(Mechanical) I Inspections (Electrical)
Secondary Contact:
Inspections(Plumbing) W Inspections(Complete)
Position:
NOTE:Private Provider to perform all inspections in the category selected.
Phone #:
Name of Firm: A E Engineering Inc.
Primary Contact: Rob Myrick
Phone#: 904-531-5154
Q{ �,/�4 h OWNER& PROJECT INFORMATION
Permit Number:Rt..x. cJs — 00).c. D—fjResidential Commercial
Address: 31crAmoi �. l,\yhG tC,�,11 3�2 3�
Property Owner: 11,12_1 k,(2-41 k Individual Corporation Partnership
Primary Contact odWe t ` 111 APhone it: C\Q-Q _ —oci 11
I have elected to use one or more private providers to provide inspection services on Permit listed above.I also acknowledge that I,the property
owner, am in contract with the Private Provider firm,as specified in FS.553.791(Florida Statutes). I understand the local building official will not
perform the required inspections to determine compliance with applicable codes,except to the extent specified by law.Instead,inspections will
be by licensed or certified personnel identified in the application. The law requires minimum insurance requirements for such personnel. By
executing this form,I acknowledge that I have made inquiry regarding the licensed or certified personnel and the level of the 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 services with respect to the building that is the subject of the enclosed permit application.
I attest this information is true and accurate to the best of my knowledge. NOTARY AS TO OWNER y
,
Before me this qday of /Slay ,zo 2i
Personally appeared Otte‘ Z , 14V(-key
Who executed the foregoing instrument and
�-- acknowledged before me the same was
roperty Owner Sign e caner &Authorized Agent executed for the purposes therein expressed.
-1,4/ii1 1 r •1)f2Lit Type of ID produced: AZ Dr;. ‘c.cil
Notary(Signatur .
Print Name
Printed Name: Jo�.� Ma R
My Commission Expires: Nr--:\ 2..1 r 20 2V
Date S-. /` / L /
;;;«%►i; JOHN MARTIN
+c . .�:compi4sion i G 39R915
1-. Expires April 29,2023
'•F1:•;n°0* Bonded The Troy FalnInsurance 800-3857019