PW-17-2523 PBf7711t nro. P W-1 -17-2523
`yHo�„s`�! Miami Shores Village Permit Tom:Public Works
10050 N.E.2nd Avenue NEP
erl I I' I WO&Ciessification:Public.Werks
Miami Shores,FL 33138-0000 Petmit'StafuS:APPROVED �
Phone: (305)795-2204
�ORiDA
Issue Date: 11/812017 Expiration: 02/06/2018
Project Address Parcel Number Applicant
9830 NE 5 Avenue Road 1132060172050
EDWARD O DONNELL
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
EDWARD O DONNELL '0830 NE 5 Avenue Road
MIAMI SHORES FL 33138-
9830 NE 5 Avenue Road ,
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $ 1,500.00
TRUST CONSTRUCTION GROUP LLC (954)227-8777
Total Sq Feet: 660
Scanning: 1 Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
I
tajwP.
t
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF' $0.60
DBPR Fee InvOICe# PW-10-17-65437
$0.00
DCAFee $0.00 10/24/2017 Cash $50.00 $54.60
'
Education Surcharge $0.20 11/08/2017 Cash $54.60 $0.00
Permit Fee $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $104.60
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 incompliance with all applicable laws regulating
construction and zoning. Futhermore,I authorize the above-named contrpLgtor to do the work stated.
November 08, 2017 '
Authorized Signature:Owner / Applicant / Contract / Agent Date
Building Department Copy
November 08,2017 1-
Miami Shores Village RECE'v F®
Public Works Department QST 2 4 2 ��
(305)795-2210
Pub' works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores,FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type:Work in the Right-of-Way on Miami Shores Village or Miami-Dade Property �{
Permit#: �Vy 1�—2S-2J
F
Name of Applicant(if utility see below):
Owner off the following described property:
Legal Description: Lot 1711
t/ Block Subdivision
Folio#; ),� > — o/7 — Zo v
Address: xn aer Z?Q
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration#: Certificate of Competency#
CONTRACTOR NAME: 6/'a'
Qualifier/Authorized Agent: i 14 10,Ald
Address: .SL / �i✓� a�
City: S ZIP:
.?0-7 3 4
Telephone: Email: L�4iOJGdOc2.lJ�t- d�L�n% � (��r'�J
State Certification or Registration#: C/tZ/�'2o/6% Certificate of Competency#:
Requests permission to install (describe work,attach separate page if necessary)in the adjoining right of
way: /A/
i
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk 1 ElElectric ❑"" Irrigation _* �
❑ Landscape ❑ Antenna Other:
DESIGNER:Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration#:
Value of Work for this Permit: $ / O Square/Lineal Footage of Work:
***** Fees *****
Permit Fee$ 100.00
Notary$ Training/Education$0.20 Technology Fee$0.80 Scanning$ �Q
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 VccgrJ!!se.vVttkf)� after the public works permit is issued. In the
absence of such posted notice,.tiie"in,"sp�e ;o,�.# l a approved and a reinspection will be charged.
04 4.0 Signature Signature
Applicant or Authorized Agent Compan,/Utility Agent
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this---q--day of Altcmsf 20 17 ,by me this day of 20 ,by
O who lJ 6' who
CANais person known to me who has produced is pe(sovally known to me or ho has produced
las as
identification. identification.
NOTARY PUB NOTARY PUBLI
Sig Sig . Q• �.a
Print: ��_f7) ,�. 'lQu)Q'I� Print: oc/S4 _k11 J-6
SEAL: SEAL:
�--- � ._.-- -- LISA A.LAUDANDO
,•,PRY A��, LISA A. LA"DANDO =o"�Y Fl"9��: Notary Public State of Florida
Notary Public State of Florida i `2* " Commis #FF 222783
Commission#FF 222783 a* "o`er My Comm.Expires Aug 14,2019
°:' My Comm.E, 'res Aug 19.201 %,FOF Fl����, ed tnrou h National Notary Assn.
,FOFFL°. „ „ Bonded 9
���.
Bonded a hN sic # y;aa .
APPROVED Com
_ Public Works Director, or Designee
2017-04-15
S,�oRFs y
s�' � ► Miami shoresVillage
Building Department
artment
VA 10050 N.E.2nd Avenue
ORIDp' Miami Shores, Florida 33138
Tel:•(305) 795.2204
Fax: (305) 756.8972
Notice to Owner — Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees,including the owner,must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if:
1. The officer owns at least 10 percent of the stock of the corporation,or in the case of
an LLC,a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State,Division of Corporations;and
3. The corporation is registered and listed as active with the Florida Department of
State,Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a i
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers'compensation exemption and has acknowledge that he or she will not use
day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of
workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature:
caner
State of Florida
County of Miami-Dade
The foregoing was acknowledge before me this day of ��,�Q// ,20±7 .
By z�G�Iy/�U��lt'LZ_ who is personally known to me or has produced
�10�2{i as identification. 110
„„ LISA :Na!ional
DANDO
µv a
?r°`. «`� Notary Publate of Florida
No ; = CommissFr 222783
My Comm.EAug 14,2019
SEAL:
° °�I��'� Bonded througNotary Assn.
i
Trust Construction Group
5211 W. Hilsboro Blvd.
Coconut Creek, FI 33073
954-227-8777
Date: October 19, 2017
State of Florida
County of Broward
Before me this day appeared Anthony Mignano who, being duly sworn,
Deposes and says:
That he or she will be the only person working on the project located at:
9830 NE 5 Ave rd iami Shores, FI 33138
Contractors signature
Sworn to(or affirmed)and subscribed before me this 19 day of October. 2017
Personally Known--------------------
"�PaY��•V,� 7�17
AUDANDO
;s°* «`�; State of Florida OR Produced Identification--------------------
=•* q #Fi-222783 1
UF FIU T` Mes Aug 14,2019 Type of Identification Prod uced--ao��---1 -��604-c-P
��1-11 •• Bational Notary Assn.
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Print,Type,or StampName of Notary
SNOC.19322
RES G�
Miami Shores Village
loss Building Department
10050 N.E.2nd Avenue
vFtiT °�� Miami Shores, Florida 33138
�ZORCDA Tel: (305) 795.2204
Fax: (305) 756.8972
SURVEY AFFIDAVIT
STATE OF(FLORIDA)
COUNTY OF(DADE)
The undersigned Affiant, C%J1-^64D dAr�z�-&,does hereby attest that
(Property owner)
The attached survey, performed by 1�eA E L i(r AS o{1,4 TG:::j
(Name of surveyor's company)
For address: � �pp 0 /Y S '4�X
Performed on (date of survey) is an accurate representation of the existing conditions and
locations of all structures on the property as of this date.
The purpose of this Affidavit is to induce Miami Shores Village to issue a building permit for the property
without first providing a survey less than seven (7) years old old. The Affiant, as property owner, further agrees to
remove or obtain permits for any structures which.now may exist on the property which are not permitted or which
may violate zoning or building code regulations. The Affiant further understands that the existence of,any such
structures may affect final inspections as applicable to this or other permits.
Further,Affiant say eth naught. 1
Prop wner Signature Property Owner Print Name
SWORN TO AND SUBSCRIBED before me this day of
Affiant is personally known to me, produced Ro" l ,Vd' as identification.
""""• LISA A.LAU:NA
Notary Public-Storidar_�f�
° •- Commission# 83
9f My Comm.Expires 2019 Notary
Bonded through Natiossn.
Revised(6/25/12)Revised on 5122/2009/Revised on 6112109
ORES
C:FH H 21-117 R 05 9 0 9 :L e-
Miami Shores Village
0 0R BK 30725 P3 1021 (1P9s'j
Building Department
J.;V.2ijl 7 "11
- -
10050 N.E.2nd Avenue I RA,iE VT�4
A. tRAK 0
0 D 0 L!1'41'T F'- +"151
Miami Shores, Florida 33138 C,
14
Tel: (305) 795.2204
Fax: (305) 756.8972 S'"ATE OF FLORIDA,COUNTY OF DADE Co
I HEREBY CERTIFY that this is a true copy of the
. . I filed* this ffabe on-------day of CLUX
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY 7,0' 1'� N11 10
TNESS9,��'f_ and Official Seal.
Whereas, (owner)
Hi RVE U CLERK' pit and County Courts N GOD WE ESA
hereinafter referred to as the owner of the following describes U C. co
property (address): ffF v lvzz- r le9e - C., TDVX0fFM
Legal Description: Lot/7 .,;, Block Subdivision 17
Folio # 3 Zo
Requests permission to install (describe work):
Within the public right of way of (address)
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 representative).
Signature / /
Owner or Agent
State of Florida
C o u my of Miami-D-adf_-6v u
The foregoing instrument was acknowledged-lieif-6-re--m--e�this-__�day of /Ig-,j�- 20 /7 by
who is personally known to m 11 r who has produlced
as identification.
NOTARY P 0c.
I C
P_ LISA A.LNUIDAMID0 �,p
Sign: b
Notary Public-State of Fjorida
A
mi2sion V, -222783
�j Fir
Print:
my C o mnE,,-iresAligI4,2019
Ass
n
-77
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EXAMINATION OF THEABSTRAETOFTGLEWILLHAVETOBEMADETODETERMINE RECORDEDINST�1� T3' ANY,Ar TING THE PROPERTY.
THIS SURVEY IS SUBJECT TO DEDICAT:ONS.LIMITATIONS.RESTRICTIONS,RESERVATIONS OR EASEMENTS OF RECORD. W <`—
! �I LEGAL DESCRIPTIONS PROVIDED BY CLIENT OR ATTESTING TITLE COMPANY. J 'r c z<'y^J
UNLESS OTHERWISE NOTED,THIS FIRt.I HAS NOT ATTEMPTED TO LOCATE FOOTINGS AND!OR FOUNDATIONS. v r54
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THE FLA FLOOD INSURANCE RATE MAP DATED 79 PUBLISHED BY THE UNRED STATES DEPAATk.N7OF HOUSBY `,'——===—=2
7` ,7. :a. _ •Q I r ;•�G;H _ -_ 1F t7 t •AND URBAN DEVELOPMENT,DELINEATES THE HEREIN DESCRIBED LAND TO BE SITUATED WITHIN ZONE _ n u u n n u u w u p
--149•1.t. .�z 75. 7. _ Community No Panel No /yam r�.� Suffix: —
FIELD WORK ______'� a
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����!/UiOa' /uS�f /'^%°1 / L2� �'�-•�'� �� (L L/��Y ,� I Fieltl Book �i\/Q r Ct. Date (� Q- DIANE V.WARD - -----
t CHRISTOPHER P.KELLEY E
This certifies that-a survey of the property.ilescbbed hereon was, ATTORNEYS TITLE INSURANCE FUND,INC.
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'�'•' '�1!?.( made under my supervision and that the survey meets the minimurr — _
technical standards set forth by the Florida Board of professional land COUNTRY WIDE FUNDING CORP.
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surveyors m cha ter ITS SUCCESSORS AND/OR ASSINGS` z
T 1��':�/�t� f' Y p ,6 L�a t-,Florida Administrative code,pursu ^<
ant to section 472.027,Flondalstatutes.And,that the sketch hereon•
- -- is a true and accurate representation thereof to the best of my AS THE INTEREST MAYAPPEAR F z "-
knowledge and belief.Subject to notes and notations shown hereon. r..77,n
\ BAEZ & ASSOCIATES, INC. <<=V J V U U V
NOTES-. 18 ,a.5 P N DL j {SAV SNI _ S STATE OF FLORIDA O car E.Baez-Cusido P.L.S.N°5034 LAND SURVEYOR"�'
!! .LAND PLANNERS u n n u u u n n n
1. IF SHOWN.BEARINGS ARE REFERRED TO AN ASSUMED MERIDIAN,BY SAID PLAT IN THE DESCRIPTION OF THE PROPERTY. DATE: to-1,2- 11-1 Order N°T440-I I Cp(p 424 S.W. 63rd Ave.::-Miami, Florida 33144 T Y Z
IF SHOWN,ELEVATIONS ARE REFERRED TO N.G.V.D.OF 1929. � �--- Not valid, unless Signed Dated 8 Stamped with embossed seal Office: (305)265-1002•.Fax: (305)265-0608 •---_ ;—p
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