PW-18-1284 Permit No. PW-5-1 8-1284
y ..1R Miami Shores Village Patmit Type:Public Works
�r 10050 N.E.2nd Avenue NE
e'' rt� ' Work Classification:Public Works
Miami Shores,FL 33138-0000 PPermit Status:APPROVED
yF-- Phone: (305)795-2204
�ORtDp'
Issue Date:5/22/2018Expiratii on: 08/20/2018
Project Address Parcel Number Applicant
9830 NE 5 Avenue Road 1132060172050
Miami Shores, FL 33138- Block: Lot:. EDWARD O DONNELL
Owner Information Address Phone Cell
EDWARD O DONNELL 9830 NE 5 Avenue Road
MIAMI SHORES FL 33138-
9830 NE 5 Avenue Road
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone Valuation: $11,500.00
TRUST CONSTRUCTION GROUP.LLC (954)227-8777
�_ ._ __..... Total Sq Feet: 660
Scanning: 1 Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
Fees Due Amount Pay Date Pay Type Amt Paid Amt Due
CCF $0.00
DBPR Fee Invoice# PW-5-1&67535
$0.00 05/15/2018 Cash $ 50.00 $54.00
DCA Fee $0.00
Education Surcharge $0.20 05/21/2018 Credit Card $54.00 $0.00
Permit Fee $100.00
Scanning Fee $3.00
Technology Fee $0.80
Total: $104.00
r
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 FIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructi n zo ing. Futhermore I au a above-named contractor to do the work stated.
May 21, 2018
Aut ize Signature:Owner / Applicant / Contractor Agent Date
Building Department Copy
May 21, 2018 1
-mss- Miami Shores Village
Public Works Department
(305)795-2210 ' -f - J
Public works forms are available from the building department, 10050 NE 2nd Ave.,Miami Shores,FL 331 AY 1 5 18
PUBLIC WORKS PERMIT APPLICATION
Permit Type:Work in the Right-of-Way on Miami Shores Village or Miami-Dade Property'
Permit
Name of Applicant(if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio#; .nn �n
Address: tai Q am6 I ► 11 R_N SVWCS 3_31-DO
�v
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration#: Certificate of Competency#
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Addre s: 2lk W - 1\
City: Q Or OYCCUState: ZIP:
+" Telephone S E ail: ✓1 ►►- "(Y-)State Certification or Registration#: Certificate of Com etency#:
Requests permiss'on to install (describe work,attach se arate page if necessary) in the adjoining right of
way: aV0a M(
Type of Work:x Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER:Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration#:
Value of Work for this Permit: $ ✓ Square/Lineal Footage of Work: _QD
1 ***** Fees *****
Permit Fee$ 100.00 �j GIC so
I Notary$ Training/Education$0.20 Technology Fee$0.80 Scanning$
Bond $ (if required) Total Fee Now Due$ IEq • QO
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. 1 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.
Si natur Cl/��� Si nature
g g
Applicant or Authorized Agent Company/Utility Agent
oregoing instrument was acknowledged before The foregoing instrument was acknowledged before
this 9 day of 20by me this q day of 20 Ik ,by
D �L� k 0 A who - who
is personally known to ice- .Zr who has produced ispersonally know t me who has produced
as as
identification. identification.
NOTARY PU IC: NOTARY PUBL
Sign: �/ Qt,�2('0 Sig
Print.ZS Print: GC/SG
SEAL: -��� w SEAL:
+' LISA A.LAUDANDO ,• LISA A'�LAUDANDO
• RY PV: r �� �::
.wo,
. ,� P0.Y PV' Plotary Public-State of Florida 20* °� Notary Public-State of Florida
Commission#FF 222783 5Commission#FF 222783
W My Comm.Expires Aug 14,2019 I ; ' My Comm.Expires Aug 14,2019
°��� Bonded through °,,FoaF��.�
++++ Bonded through National Notary Assn.
APPROVED BY: Public Works Director,or Designee
2017-04-15