PW-17-1205 : Peart = �7-1206
3
Miami Shores Village X71 Pgolio Works
10050 N.E.2nd Avenue NW WdI Cl s i Old PubllC k
Miami Shores,FL 33138-0000
Pert»itStaflis:' "PRP,
Phone: (305)795-2204 .
pOR
' at I, 91T Expiration: 1712017
Project Address Parcel Number Applicant
241 NW 92 Street 1131010331180
PERFECT HEAT
Miami Shores, FL Block: Lot:
Owner Information Address Phone Cell
PERFECT HEAT LLC 241 NW 92 Street (305)608-4672
MIAMI SHORES FL
241 NW 92 Street
MIAMI SHORES FL
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
LELACK CONSTRUCTION (954)263-7120 Total Sq Feet: 450
Scanning: 1 Available Inspections:
Inspection Type:
Excavation
Review Planning
Review Public Works
Review Public Works
Final Public Works
Fees Due Amo]$3.00
Pay Date Pay Type Amt Paid Amt Due
CCF Invoice# PW-6-17-63881
DBPR Fee
DCA Fee 05/19/2017 Credit Card $ 104.20 $0.00
Education Surcharge
Permit Fee $
Scanning Fee Technology Fee Total: $10
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans,drawings,statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL,PLUMBING,MECHANICAL,WINDOWS,DOORS,ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore,I authorize the above-named contractor to do the work stated.
May 19, 2017
Authorized Signature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
May 19,2017 1
F �
� ���- � r�
RECEIVE®
Miami Shores Village
Public Works Department MAY - �0��
(305)795-2210
Public works forms are available from the building department,10050 NE 2"d Ave.,Miami Shores,FL 33138 U�-4
PUBLIC WORKS PERMIT APPLICATION
Permit Type:Work in the Right-of-Way on Miami Shores Village or Miami-Dade Property
Permit#: Vy 19- 12-05 0
Name of Applicant(if utility see below): qAo ?�>I m
Owner off the following described property:
Legal Description: Lot_ Block T3 S Subdivision A vem 3�l orLZ>
Folio#;
Address: Q41 m 15� kA.uptml lshc 'ems
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration#: Certificate of Competency#
CONTRACTOR NAME: Lelnor CC -I rur t Oman
Qualifier/Authorized Agent: o Lxln CSS
Address: C;5:Z�J N. S, -, , -e_ YZ-3 'I `'c%A o
City: Cdc c cA Crte e_,r- State: IAC✓ ZIP: 3301-±>
Telephone:9,4.1122go 12s] Email:
State Certification or Registration#:GGc I ss 1,,4C,&A g Certificate of Competency#:
Requests permission to install(describe work,attach separate page if necessary)in the adjoining right of
way: Esrlcx_ Pc�,er� �JrtUe4'�L .1
Type of Work: Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER:Architect/Engineer:
Address:
City:" State: ZIP:
Telephone: Email:
Registration#:
Value of Work for this Permit: $1 SCx:>.00 Square/Lineal Footage of Work:
***** Fees *****
Permit Fee$ 100.00
Notary$ Training/Education$0.20 Technology Fee$0.80 Scanni g
Bond$ (if required) Total Fee Now Due$
Bonding Company's Name(if applicable):
Bonding Company's Address:
City: State: ZIP:
Application is hereby made to obtain a public works permit to do the work in the right of way and
installations as indicated. I certify that no work or installation has commenced prior to the issuance of a
permit and that all work will be performed to meet the standards of all laws,regulation construction in
this jurisdiction. I understand that separate permits must be secured for
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be
done in compliance with applicable laws regulating construction and specifically construction in the
right-of-way.
"WARNING TO APPLICANT:YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN
YOUR PAYING TWICE FOR IMPROVEMENTS TO THE RIGHT-OF-WAY. IF YOU INTEND TO OBTAIN
FINANCING,CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF
COMMENCEMENT."
Notice to Applicant:As a condition to the issuance of a public works permit with an estimated value
exceeding$2,500,the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment.Also,a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7)days after the public works permit is issued. In the
absence of such posted notice,the inspection will not be approved and a reinspection will be charged.
Signature Signature,
Applicant or Authorized Agent Company/Utility Agent
The foregoing instrume t was acknowledged before The foregoing instrument was acknowledged before
me this d day of 20_)tE:,- by me this 2na day of cw 20-E��by
who A c lQ k who
is personally known to me or who has produced is personally known to me or who has produced
as as
identification. identification.
KYLE C HAMBRICK
KYLE C HAMBRICK
NOTARY I
MY COMMISSION#GG086511 NOTARY PUBLIC ;'"s MY COMMISSION#GG066511
E 28,2021 ,ps .•' EXPIRES January 26,2021
Zrint
Sign:
l/ I r„�
zPrint:
SEAL. SEAL:
APPROVED BY: Public Works Director,or Designee
2017-04-15