PW-17-1500Protect Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Parcel Number
Permit NU `W- -' -151
:.Public Wo
Work Classification; .PI
??root Status:: APPROVED
, a /6120' Expiration: 09/04/2017
Applicant
250 NE 96 Street
Miami Shores, FL 33138-
1132060133880
Block: Lot:
BONNIE BENNETT
Owner Information
Address
Phone
CeII
BONNIE BENNETT
250 NE 96 Street
MIAMI SHORES FL 33138-
(305)756-8988
250 NE 96 Street
MIAMI SHORES FL 33138-
Contractor(s)
CHAMPION CONCRETE
Phone Cell Phone
(305)252-8055 (786)402-4802
Valuation:
Total Sq Feet:
$ 2,100.00
300
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.00
$0.00
$4.50
$0.20
$100.00
$3.00
$0.80
$108.50
Pay Date Pay Type
Invoice # PW -6-17-64229
06/06/2017 Credit Card
06/06/2017 Credit Card
Amt Paid Amt Due
$ 58.50 $ 50.00
$ 50.00 $ 0.00
Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
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 mys 1', my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ' OOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information s accur. a and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futhermore, I authorize the above -nam 1,. ntr for o do the work stated.
June 06, 2017
Authorized Signature: Owner / pplicant / ontracto'l Agent
Building Department Copy
Date
June 06, 2017 1
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE rd Ave., Miami Shores, FL 33138
RECEIVED
1UNn0�1p�7
CIC.
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miaml-Dade Property
Permit#:
Name of Applicant (if utility see below): UDN#/'�E�—
Owner off the following described property:
Legal Description: Lot 0)4-7 Block z9 Subdivision 711,1,04-/
Folio #; 1/ -19,46 - D i3 — .38'gra o�Sa r�/c '7&Sri
Address: _ _
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: 07 / t//D,t'/ C9 etf EY
Qualifier/Authorized Agent: X714 j,fl z A -,S 11- i o
Address: 1 La's tuitr 63 T -tit- /
City:N MiPt State: ZIP: 3 ' or
Telephone: 3O5 7 Z- (Y2f Email:
State Certification or Registration Certificate of Competency #: Ec)c,c eo//j.
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: s/P E //? tK OLl'%-
Type of Work: 0 Paving 0 Utility Sidewalk 0 Electric 0 Irrigation
0 Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration #:
Value of Work for this Permit: $ 1,100 Square/Lineal Footage of Work: 3 0 &� lc-
***** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
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: 1 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 . t the job
site for the first inspection which occurs seven (7) days after the public works permit is issu . In the
absence of such posted notice, the inspection will not be approved and a reinspection will ,e charged.
Signa
Applicant or Authorized Agent
The foregoing instrument w acknowledged fore
me this __J day ofp/ , 20 by
`lO,vI'L I4Nu 4Nt7T who
is personally known to me or who has produced
ct--D (L.1V2`+- /ac..( as
identification. ...&--3 O06 /SS( P.42- /
NOTARY PUBLIC:
Sign: pp
Print: ,�j/%)/,✓/0/t/d.% 2— /'4A-1'
SEIy •
w w
APPROVED BY:
2017-04-15
EMMANUEL REGIS
MY COMMISSION # 06 074786
EXPIRES: Apra 14, 2021
Rader 71w Nosy Public Underwrites
Signature
Com
The foregoing instrum
me this ce, day of
Pcr rri
ny/Utility Agent
was acknowledged before
20 1�. , by
who
Is personally known to me or who has produced
„(�
identification. N‘N011\11S'0/ ii�i��
• 09L456 d #
as ; y
X06111111110
NOTARY PUBLIC:
Sign:
Print:
SEAL:
*****i**.**************************************
L\
, Public Works Director, or Designee
Thin- (sQg
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