Form # 9b-3.053-2002-01 - Notice To Building Official Of Use Of Private Provider Page 2
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1
2The 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: A private provider may 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 performed as a private provider. 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 higher 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 insure claims-made coverage to fulfill this
requirement, the private provider must also maintain coverage for a minimum of 5 years subsequent
to the performance of building code inspection services.
The insurance required under the
subsection shall be written only by insurers authorized to do business in the state with a minimum
A.M. Best’s rating of A. Before providing building code inspection services within a local building
official’s jurisdiction, a private provider must provide to local building official a certificate of
insurance evidencing that the coverage required under this subsection are in force.
Print Name of Corporation or Partnership: ____________________________________________________
(if applicable)
By: ______________________________________________________________________________________
(Signature of individual, or on behalf of the state corporation, or a partnership)
Print Name: _______________________________________________________________________________
Address: ________________________________________________________________________________
Telephone Number: ________________________________________________________________________
STATE OF FLORIDA
COUNTY OF ______________________________
Before me, this _____ day of __________________, 20 ____.
Personally appeared _________________________________
Check One:
as an individual;
as officer on behalf of the state corporation;
as a partner of the partnership
who executed the foregoing instrument, and acknowledged before me that same was executed for the purposes
therein expressed.
Personally known ________; Produced identification ______.
Type of identification produced ____________________
__________________________________________
__________________________________________
Signature of Notary
Print/ Type/ Stamp Notary’s Name
CITY USE ONLY
Approved by:
Date:
2 of 2
Page
Modified: 10.22.2012
G:\Zoning 2009\Forms and Sample documents\Website Documents\Building\Forms \ noticetobuildingofficial.pdf
Form # 9B-3.053-2002-01
Effective: January 20, 2003
Revised Florida Statue 553.791
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