PW-18-880Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permit
Parcel Number
tsaue :Date: 4/ 10/2018
Permit NO. PW-4-f 8-880
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Expiration: 07/09/2018
Applicant
9740 NE 13 Avenue
Miami Shores, FL
1132050090450
Block: Lot:
JANICE MOST PICKARD
Owner Information
Address
Phone
Cell
Contractor(s)
CHAMPION CONCRETE
Phone , Cell Phone
(305)252-8055 (786)402-4802
Valuation:
Total Sq Feet:
$ 2,800.00
360
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
$0.20
$100.00
$3.00
$0.80
$104.00
Pay Date Pay Type
Invoice # PW-4-18-67044
04/10/2018, Check #: 2837 $ 54.00 $ 50.00
04/05/2018 Check #: 2829 $ 50.00 $ 0.00
Amt Paid Amt Due
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 conf.rmity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I assume r •ponsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRICAL, PLU =1NG, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: cert. that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zoning rmore, I authorize the above -named contrac Cr to do the wg tated.
Authorize f ignature: Owner / Applicant / Contractor / Agent
April 10, 2018
Date
Building Department Copy
April 10, 2018 1
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores
REG.
APR 05 20 8
a 3138 A `�
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Perm it#:1el
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Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio#; 32-05_0 5D
Address: ' 72t0 /4,E l.3 .0( V
Name of Applicant (if utility see below):
2
Telephone: -Email:
Registration #:
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: AA*piaA) Cedivcivetee
Qualifier/Authorized Agent: '4-1Ji,e_ JA5ji 4 D.
Address: J D2-d'O P1w (a•eitil
City: °Att. State: 44_ ZIP:
Telephone:3llj:2. ` O9' Email:
State Certification'or Registration #: Certificate of Competency #: <eC>5.64 Oe
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: COtkrIb�7`e 6/j S M—
CI
Type of Work: ❑ Paving ; ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address: :'
City: _ State: ZIP:
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Value of Work for this R,ermit: $ Zr0 d (� A Sgzare/LireahF�ootage of'Wok'
*****Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ . CA
J
iK
t 0
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
II A t .
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. I
1
"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 1 III be charged.
t�
Signature „ //`� l� f 1(10'~1 Signature
Applicant or Au orized Agent Company/Utility Agent
The fore . g instrume was acknowledged before 14The foregoing instrument was acknowledged before
;me this _ i eday of ` 4 20 -*by C_)'me this day of r , 201' , by
.1Q,A t E. M oST who who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Sign: QL-(QC
Print:
SEAL:
•-
•
AMARELTS MENA
MY COMMISSION M FF 996927
EXPIRES: June 2, 2020
Bonded TMu Nob y Public Undenrrne s
APPROVED BY:
2017-04-15
is ersonally known to me or who has produced
111-)6z 13A-SiU iS as'
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
01111111111/
•
:
o /FF 954760
�ACI, i�As�
*******rk*************************************
, Public Works Director, or Designee
A
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
I 111111 IIiii 11111 hill 11111 11111 11111 IIII 1111
C F N 201uRC 86c9-3-y.
OR 'BK. 30917 Ps 393 (1 Ps s )
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LAR FkvIrCLERKQFC[u:i; .
MIAMI-DAtDE CSil_iliy FLORIDA
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) f!} 'e /`t0:0 / re/C'
hereinafter referred to as the owner of t e following described'
property (address): q?!IO /!/t '34V i 'tk 3'v,C W, iib/.
Legal Descri tion Lot Block Subdivision
Folio # ('/ 32i75- c9 q-. 0it_S- * ..
Requests permission to install (describe work): ,
Within the public right of way of (address)
�7V J '' /,3 zE1 3 31
IN CONSIDERATION of the approval of this permit bythe Village, the owner agrees as follows:
I?P 9 9
•
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.publiic 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 abovedescribed property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores' Village or Dade County
- ---harmless from -any -and Alliability,-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, I}'s fully authorized representative).
Signature
State of Flhlr'da
Af
Owner r Agent
County of Miami Dade
The foregoing insfrum nt was acknowledged before me
�a R i C( f lAr si r ck rd who is
as identification.
NOTA_
Sign:-P`
Print A-�s eJ1c m 4
PUBLIC:
this day •f
personally known to me or who has p • duced
SEAL: