DW-17-2129RECEIVED
AUG 232017
Public works forms are available from the building department,f10050 NE 2nd Ave., Miami Shores, FL 33138
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Miami Shores Village
Public Works Department
(305)795-2210
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
044
ermit,e,#: PW-1-16-181 (Renewal)
1R - 2129'
Name of Applicant (if utility see below):
Miami Dade Water & Sewer
Owner off the following described property: ��
Legal Description: Lot 21 Block Subdivision Shoreland Hgts
Folio #; 1121360020240
Address: 11004 NW 2 AVE
UTILITY NAME: Miami Dade Water & Sewer
Qualifier/Authorized Agent: Maria Gonzalez (WASD)
Address: 20800 SW 117th Ct.
City: Miami
State: FL
Telephone: (786)268-5097 Email: MGONZ1@ d:d .gov
State Certification or Registration #: `'' .4iir'i ;,'date of Competency #
CONTRACTOR NAME: Miami Dade Water & Sewer
ZIP: 33177
Qualifier/Authorized Agent: Maria Gonzalez (WASD)
Address: 20800 SW 117th Ct.
City: Miami
Telephone: (786) 268-5097
State: FL
Email: MGONZ1@miamidade.gov
ZIP: 33177
State Certification or Registration #: Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: Install Service Point
Type of Work: ❑ Paving ! Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
e ❑ Antenna ❑ Other:
DESIGNER: Architect/En i
Address: LED
City: State: ZIP:
Telephone: Email:
Registration #:
Value of Work for this Permit: $1,200.00
Square/Lineal Footage of Work:
***** Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
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 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.
I' Signature
Applicant or (garthorized Agent
The foregoing instrument as acknowledged before
me this )7 day of nit , 20 % f , by
Maria Gonzalez (WASD) who
me c%ywho has produced
Is
perso
all
know
identification.
NOTARY PUBLIC:
•
Si
gn• _
Print:
SEAL:
F
Signature
Compan Utility Agent
The foregoing instrument as acknowledged before
me this I ' day of Jy)/ , 20 17 , by
Maria Gonzalez (WASD) 1 who
erso all know to me or who has produced
as 4
ci§Yt to
APPROVED BY:
�• _ Notary Public - State of Florida
•• Commission # FF 898772
, My Comm. Expires Jul 29, 2019
Bonded through National Notary Assn
Pc
identification.
NOTARY PUBLIC: •
Sign•
Print: Fran
SEAL:
as
'WNW.� FRANCISCO 6ARi
atdrJ;�..i . - Public = State of Flo
r •‘ Commission # FF 89
` • My Comm. Expires Jul 2?9
`• r
��-� 'a:• ivi � Bonded through National Note
* * * * * *************************************
, Public Works Director, or Designee
2017-04-15