Fillable Form 20: Community Development Department (Charlotte County BCC)

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Form 20: Community Development Department (Charlotte County BCC)

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Community Development Department
Building Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
”To exceed expectations in the delivery of public services”
For Office Use Only
PLANS EXAMINERS
INITIALS
12/2009, mag
20
Business Address:
Home Address:
Business Phone: Fax No.
Certificate Holder's Signature:
Certificate Holder's Name:
County of:
PRIVATE PROVIDER REGISTRATION FORM
Please submit the following documents. All items must be included to process. Instruct your insurance company to fax certificates of
insurance directly to Charlotte County as well as to the qualifier and include documents with finished packet. Allow three (3) business
days for processing mailed documents.
1. Copy of current State License
2. Occupational License from qualifiers home county
3. Current Driver's License
4. Certificate of Insurance for General Liability and Worker's Compensation or qualifiers exemption card. Certificate must list
Charlotte County Building Construction Services as as certificate holder.
5. List of Inspectors/Plans Examiners to include their BN/PX numbers.
Name of Business:
Certificate Classification:
Certificate Number:
Federal I. D. #: Date of Birth:
Business Mailing Address:
Home Phone:
(Power of Attorney not Accepted)
STATE OF FLORIDA
The foregoing instrument was acknowledged before me this
day of
20
by
who is personally known to me or has produced
as identification and who did/did not take an oath.
Notary Seal
Signature of Notary:
Notary's Printed Name:
Commission Number:
Community Development Department
Building Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
”To exceed expectations in the delivery of public services”
For Office Use Only
PLANS EXAMINERS
INITIALS
12/2009, mag
20
I have elected to use one or more private providers to provide building code plans review and/or inspections 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
adequateley 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, udate 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.
into a contract with the Private Provider indicated below to conduct the services indicated above.
Project Name:
Parcel Tax ID:
Services to be Provided:
Plans Review
Inspections
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 sued for both services pursuant to Section 553.791 (2) Florida Statute.
Notice to Building Official For Use of Private Provider
I,
, the fee owner, affirm I have entered
Private Provider Firm:
Private Provider:
Address:
Phone:
Fax:
Email Address:
Florida License, Registration or Certificate #:
Location/Address:
Lot:
Block:
, 20
day of
The foregoing instrument was acknowledged before me this
County of
State of
by
Signature of Notary
Notary's Printed Name
Notary Seal
of
Name and Title of Officer or agent
Name of Corporation
a
state or place of incorporation
corporation, on behalf of the corporation, who is personally known to me
or has produced
as identification and who did/did not take an oath.
Signature of owner:
Please Print Full Name
Community Development Department
Building Division
18400 Murdock Circle | Port Charlotte FL 33948
Building Phone: 941.743.1201 | Building Fax: 941.764.4907
BuildingConstruction@CharlotteCountyFL.gov
www.CharlotteCountyFL.gov
”To exceed expectations in the delivery of public services”
For Office Use Only
PLANS EXAMINERS
INITIALS
12/2009, mag
20
personally know to me or has produced
Print Name
Print Name
Notary's Printed Name
Signature of Notary
Address
as identification and who did/did not take an oath.
Notary Seal
PLEASE USE APPROPRIATE BLOCK
The following attachments are provided as required:
1. Qualification statements and/or résumés of the private provider and all duly authorized representatives.
2. Proof of Insurance: A private provider ma perform building code inspection services on a building project under this section only if the private provider maintains
insurance for professional liability covering all services. Such insurance shall have minimum policy limits of $1 million per occurrence and $2 million in the aggregate for any
project with a construction cost of $5 million or less and $2 million per occurrence and $4 million in the aggregate for any project with a construction cost of over $5 million.
Nothing in this section limits the ability of a fee owner to require additional insurance or height policy limits. For these purposes, the term "construction cost" means the
total cost of building construction as stated in the building permit application. If the private provider chooses to secure claims-made coverage to fulfill this requirement, the
architect or engineer must also maintain coverage for a minimum of 5 years subsequent to the performance of building code inspection services. The insurance required
under this subsection shall be written only by insurers authorized to do business in this state with a minimum A.M. Best's rating of A. Before providing building code
inspection services within a local building official's jurisdiction, the private provider must provide to the local building official a certificate of insurance evidencing that the
coverages required under this subsection are in force.
Print Name
Address
Notice to Building Official of Use of Private Provider (con't)
Telephone No.:
, 20
who is personally known to me or who has produced
Signature of Notary
Notary's Printed Name
INDIVIDUAL
Signature:
The foregoing instrument was acknowledged before me this
State of
County of
Telephone No.:
Address
Print Corporation Name:
CORPORATION
by ( signature):
ITS
day of
, 20
day of
The foregoing instrument was acknowledged before me this
County of
State of
by
Signature of Notary
Notary's Printed Name
Notary Seal
of
Name and Title of Officer or agent
Name of Corporation
a
state or place of incorporation
corporation, on behalf of the corporation, who is personally known to me
or has produced
as identification and who did/did not take an oath.
PARTNERSHIP
Print Partnerhsip Name:
by (signature):
ITS
Telephone No.:
State of
County of
The foregoing instrument was acknowledged before me this
day of
, 20
by
Name of acknowledging partner or agent
, partner (or agent) on behalf of
Name of partnership
as identification and who did/did not take an oat.h.
, a partnership, who is
Notary Seal
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Form 20: Community Development Department (Charlotte County BCC)

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Completed 13 February 2021

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