PW-18-566 RECEIVEC
Miami Shores Village MAR O 6 ZR�B
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave.,Miami Shores, FL 3313 \
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: Lof Block Subdivision
Folio#;
Address: - 7
r
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration#: Certificate of Competency#
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address: 1935, L i
City: LliG 1,00 6 State: ZIP: 3 31 Oa
Telephone: 140 Email: 6 �p _
State Certification or Registration#: O� Certificate of Competency#:
Requests permission to install (describe work,attach separate page if necessary)in the adjoining right of
way:
Type of Work: ving ❑ Utility ❑ Sidewalk ❑ • Electric ¢, Irrigation
❑ Landscape ❑ Antenna ❑ Other:
1
DESIGNER:Architect/Engineer:
Address: - t
City: Stater ZIP:
Telephone: Email: 1�:14-. ...-#".-"..ff.5.:�.-,., r,. �...,.,.r..
Registration#: h4:)
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2L� �Yi ti:i?9V+,i•�'.:tr :: r,
Value of Work for this'Permit: $ Squar'a:�re/Lineal Footage�X -of 1Nork
AU cc` tnITATL '`-I' 'gip .a.1,_.� } �'1. ., ...•r c
***** Fees *****
Permit-Fee$'100.00°—
Notary$ Training/Education$0.20 Technology Fee$0.80 Scanning
Bond$ (if required) Total Fee Now Due$ J r
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r
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F
Bonding Company's Name(if applicable):
Bonding Company's Address: FV III
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.
ti ,
Signature Signature
Applicant 6r Authorized Agent Company/Uti y ent
The foregoing instrument was acknowledged fore The forego) In trume w s acknowl ged efore
"penplly
�day of �h' 20 by, me this ( day of 20 I ,by
who gill who
knoWn to me or who has produced is persona114 known to me or who has produced
as as
identification. identification.
• NOT L NOTARY P IC:,Q,�
Sign. Sign: r t"��l
Print: Print:
SEAL: 'Ye MAHARAI K.GONZALEZ SEAL:
4b"
* *= MY COMMISSION#GG 044602
EXPIRES:November 2,2020 '.auuu„' MARTHA L ALVAREZ
Bonded Thru Notary Public Underwriters A 1�4""
NOTARY PUBLIC-STATE OF FLORIDA
3t •=
a` COMM.#FF154436
MY COMM.EXPIRES 09-03-2018
APPROVED BY: ✓ 1 r . Public Works Director,or Designee
2017-04-15
t k
StlOREs C:FH ?01_-BRa>I0941. 1.6
C. : Lr� OR BK. -10864• P3 4621 (1P3s)
Miami Shores Village
RI.C:IRC,FC 02i1.5/2CI:-r;
.." Building Department 1NIAN-1--';ADE :OLIN Y? I-LURI<<l-a
10050 N.E.2nd Avenue
0 Miami Shores, Florida 33138
Tel: (305) 795.2204: � �IOFi'#�f?t1Dib4�SstPTOF�ADE � coFax: (305) 756.8972 �e�
k 119f f'Y!l1+1mns afar J� eaEor
A13 20 G
COVENANT OF CZ'AnAewh
STRUCTIO WITHIN GHT F WA }:_•
S y n
Whereas, (owner) fA(?4 EYA YIaamVVI tl°'
hereinafter,referred to as the owner of the followin described ,j q+vF �tcv
property (address): X5--0 IDD S
Legal Description: Lot Block Subdivision ;
Folio# I/- 73/0',i - oa 3-e;l-� -7 v
Requests permission to install (describe work): S%frm� �,
Within the public right of way of(address) �i
IN CONSIDERATION of the approval of this permit by the Village,-the owner agrees as follows:
I
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 theOwner or(shall
constitute a lien against the above described property until paid. . I I '
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 thepublic 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, untilrsuch 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 authori2ed representative).
Signature
t
Owner or Agent
State of Florida
County of Miami Dade
The foregoing instrument was acknowledged before me this day of _, 20
__e by
V-A CAD Y -,:?6vho is personally known to me or who hasproduced
as identification.
NOTLIC:
Sign. --=-------
Print V SEAL: :'"Y'°4 MAHARAI K.GONZALEZ
*. MY COMMISSION#GG 044602
d5
EXPIRES:November 2,2020
' •,'•.FOf F�p` Bonded Thru Notary Public Underwriters r