PW-17-13091
Project Address
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Per
Permit NO. RW -5-17-1309
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Issue Date: 5124/2017
Expiration: 08/22/2017
Parcel Number
Applicant
1080 NE 93 Street
Miami Shores, FL
1132050150110
Block: Lot:
DIANE EDE-NICHOLS
Owner Information
Address
Phone
Cell
DIANE EDE-NICHOLS
1080 NE 93 Street
MIAMI SHORES FL 33138-2939
Contractor(s)
ONE STOP PAVING
Phone
(786)299-1354
Cell Phone
Valuation:
Total Sq Feet:
$ 1,100.00
220
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.00
$0.00
$0.00
$0.40
$100.00
$3.00
$1.60
$105.00
Pay Date Pay Type Amt Paid Amt Due
Invoice # PW -5-17-64000
05/24/2017 Check #: 1716 $ 105.00 $ 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 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 regoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning. Futher f - - uthgrize„the above-named contractor to do the work stated.
May 24, 2017
Aut - ed Si • r•I • _ _ : Contractor / Agent Date
Building Department Copy
May 24, 2017 1
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shor
MA`r 1 ;, 2017
s 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: !P �- 13001
Name of Applicant (if utility see below): 17(0-'�n e � 6 G`^ -o t 5
Owner off the following describedro,�eit�r:
Legal Description: Lott �lS T rock 3 Subdivisionalk% octe'e 3y -k P6 16 -71
Folio#; 11 3205 otS' 011c)
Address: 1090 U e c13
st
'moo (Aft ()/* s
3313$
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: cM e_ `S+ ip PG uir16 C.
CFl
Qualifier/Authorized Agent:
G o S Y I^,2 -c-0 c a
Address: 4400 06 n3 54
City: &i - t--Law►1 c-cState: _ ZIP: 3316-
Telephone:7S(o IRO 1 54 Email: C..0.l°sem+-la- c.« J Ck* Lc,o.
State Certification or Registration #0_.6C 1V 31141 Certificate of Competency #: 23150 0
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: B rit(C_ 1Po• u$ we 5
Type of Work: [Paving ❑ Utility ❑ Sidewalk 0 Electric 0 Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
4 Telephone: - 1 Email:
Regist"ration #:
Value -of Work for this Perrnit:.01$ L\ 0 6„0 0
•
l "
Square/Lineal Footage of Work:
*****Fees*****
220
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ JOS", 00
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
Applicant or Authorized Agent Company/Utility Agent
The foregoing instrument w s acknowledged before The foregoing instrument was cknowledged before
me this t day of 20 1 1 , by me this (6 day of 20 11 , by
DkLOE b.)kCA+o Li who CLQ -Los ACCC who
is personally known to me or who has produced is personally known to me or who has produced
as as
Signature
identification.
NOTARY P
Sign:
Print:
SEAL:
APPROVED BY:
2017-04-15
BARBARO SOBRINO
MY COMMISSION # FF 195634
EXPIRES: February 3, 2019
Bonded Tlnu Notary Public Underwriters
identification.
NOTARY PUBLIC.
0fir,°
Sign:
Print:
SEAL:
. ,., ' 1:1 MY COMMISSION # FF 195634
:1 EXPIRES: February 3, 2019
diorgy,o'' Bonded Thai Notary Public Underwriters
(ia( i? , Public Works Director, or Designee