PW-17-1424 Permit NO. PW-5-17-1424
�sO1tEs y� Miami Shores Village Permit Type:Public Works
10050 N.E.2nd Avenue NE Work Classification:Public Works
Per
Miami Shores,FL 33138-0000
Phone: (305)795-2204 Permit Status:APPROVED
�'coaioA
Issue Dates 6/16/2017 Expiration: 09/14/2017
Project Address Parcel Number Applicant
9929 NE 4 Avenue Road 1132060171280
MARVIN R LIST&MARIA T MAN
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
MARVIN R LIST&MARIA T MANERBA 9929 NE 4 AVE Road (305)858-0204
-- - - -- - - - --- MIAMI SHORES FL 33138-
9929 NE 4 AVE Road
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 4,000.00
HOME OWNER
_._ ...- Total Sq Feet: 400
Scanning: 1 Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
a
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.00 Invoice# PW-5-17-64129
DBPR Fee $0.00
DCA Fee $0.00 06/16/2017 Check#:2533 $54.00 $50.00
Education Surcharge $0.20 05/26/2017 Credit Card $50.00, $0.00
Permit Fee $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $104.00
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.
i
OWNERS AFFIDAVIT: I ertify thatjalle foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructio a d zoning. hermoreorize the above-named contractor to do the work stated.
June 16, 2017
Au horized Sig ature:Owner / Applicant / Contractor / Agent Date
Building Department Copy
June 16, 2017 1
' AA
r+ Miami Shores Village 'r�C►
R Public Works Department F/
(305)795-22109y6' `�O
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores,FL 33138 ?O,>
I
PUBLIC WORKS PERMIT APPLICATION
Permit Type:Work in the Right-of-Way on Miami Shores Village or Miami-Dade Property
Permit#:
2
�I VL.v 2 I
Name of Applicant(if utility see below): A► L,1 5T <
Owner off the following described property:
Legal Description: Lot Block Subdivision C
Folio#, l/-3 L O (o - 0/ 4 - ► 2 g-O
Address: C= n !0 GI.CJ�-� T L...
i Z of !� �' /A-✓E ✓Zo — l W4
UTILITY NAME:
Qualifier/Authorized Age
Address: 11/
City: State: ZIP:
Telephone: Email:
State Certifica ion or Registration#: Certificate of Competency#
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City: Z State: ZIP:
Telephone: Email:
State Certification or Registration#: Certificate of Competency#:
r
Requests permission to installdescribe work,attach separate page if necessary) in the adjoining right of
,�
way: R/✓Pti -�4,f4oa c,4
r
Type of Work: [Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER:Architect/Engineer: .3't►tir�rktr�rr,.
Address:
City: State:
Telephone: Email: 4 '
Registration#:
Value of Work for this Permit: $ Squa e/Lineal•Footage of'Work: 4001 s
***** Fees
Permit Fee$ 100.00
Notary$ Training/Education$0.20 Technology Fee$0.80 Scanning$
Bond$ (if required) Total Fee Now Due$ 5 CF,-00
Bonding Company's Name(if applicable)-0:
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
t
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,, a i-� r r-;
"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.
IJ
Signature Signature
-Applicant or Authorized 4gent L A +* ,Company/Utility Agent
The foregoing instrument was acknowledged before The foregoing instrument'.was acknowledged before
me this day of l� 20_(-L, by me this day of 20 by
t_�A r- Ll Z-1 U who who
is perso ally known to me or who has produced is personally known to me or who has produced
i� as as
identification. identification.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Print: =�%� 6�' '`: Print:
SEAL: ;a° O• ��n= SEAL:
=9S a�;
0z 0�5.:'?�` '+
** ***************************************
APPROVED BY. 5 f Public Works Director,or Designee
2017-04-15
s INC 93,
s Gid I I��III! fl4 Ilf��fllfi Ilf l I IIA II I Illi I��I
r '_ Miami Shores Village CFN `�}_I_117R.O339821
e� � ������ Building Department OR gY, 30575 F4 102►_I (iF`3s)
10050 N.E.2nd Avenue RECORDED 116/15/21)1? 12:211:10
" °yam Miami Shores, Florida138 HARVEHARVEYRUVIN► CLERK. OF COURT
amores,
�ORIpA MIAMI-DADE COUNTY, FLORIDA
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) M?L"IvL Lt,5-t-
hereinafter referred to as the owner of the following de cribed
property (address): 0j°l 201 N� 4T'-, -Ve_ IAlp6kOl
Legal Description: Lot I t Block I& Subdivision
Folio # It- 32D6--o I - 1280
Requests permission to install (describe work): _1�,e IVe-Way AdZ00,-ILA_
Within the public right of way of (address), 7q'2a K)& 4-7'11+V o
IN CONSIDERATION of the approval of this permit by the Village, the owner agrees as follows:
1. To maintain and repair, when necessary, the above-mentioned item(s) installed within the
dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to
make repairs or maintain said items within public right of way including restoration of street by
reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall
constitute a lien against the above described property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County
harmless from any and all liability, which may rise by virtue of permitting the installation of
these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense,
within 60 days notice by the Village to do so. Failure to comply with this notice will result in the
Village causing the item(s) to be removed and a lien being placed on the property and/or
assessed against the Owner for all costs incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running
with the land and shall remain in full force and effect and be binding on the undersigned, their
heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in
the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village
(or his fully authorized repres tative).
sl ATE OF FLORIDA,COUNTY OF DADE rNp c UN
_ 'MFREt3Y CERTIFY that this Is a true copy of the «<,K C
Signature l;U.ltJ original filed in thi fine on of
D 20
Owner or A ent WITNESS my hand and official seal.
-HARVEY RUVIN, ERK, Ircult and County Courts
State of Florida aV _. -17,/4fi o.c. °�afCou `�
County of Miami Dade
The foregoing instrument was acknowledged before me this t day of �U�' ,—,-20 1 , by
I, SISI who is personally known to me or who has produced
Somas identification.
NOTARY P LIC:
Sign:
Print: -, V L,C,!: SEAL:
;o00 P&,#^ Notary Public State of Florida
sindia Alvarez
NX,�a My Commission FF 156750
11 Expires 09/03/2018