PW-17-1240Building
OWNERS AFFIDAVI
construction and zon
Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permit
Permit NO. PW-5-17-1240
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Issue Date: 1111312017
Expiration: 02111/2018
Parcel Number
Applicant
1070 NE 93 Street
Miami Shores, FL 33138-2932
1132050160010
Block: Lot:
ALFONSO DEL CASTILLO
Owner Information
Address
1051 NE 92 Street
MIAMI SHORES FL 33138-
1051 NE 92 Street
MIAMI SHORES FL 33138-
Contractor(s)
HOME OWNER
Phone
Cell Phone
Phone
Cell
Valuation:
Total Sq Feet:
$ 100.00
100
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$0.60
$0.00
$0.00
$0.20
$100.00
$3.00
$0.80
$104.60
Pay Date Pay Type
Invoice # PW-5-17-63919
05/05/2017 Credit Card
11/13/2017 Credit Card
Amt Paid Amt Due
$ 50.00 $ 54.60
$ 54.60 $ 0.00
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 conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores Village. In
accepting this permit I ume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for ELECTRI ' PLUMBING ECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
,1(,I Authori i I :ture: Owner / Applicant / Contractor / Agent
e • artment Copy
that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
ermore, I authorize the above -named contractor to do the work stated.
November 13, 2017
Date
November 13, 2017 1
Miami Shores Village
Public Works Department
(305)795-2210 BY.
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shore's', FL 33138
Mh?O52017
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: W `1 - t24 0
Name of Applicant (if utility see below): -A1Fpr1SO a`6 CQ$}; j`Cj
Owner off the following described property:
Legal Description: Lot Block
Folio#; 1\-32O5-01b--OC)ZC)
Address: I(no NE q3 P-0 ��4
Subdivision
UTILITY NAME: }�'QMA. OW Wit V
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in tt;aeadjoining right of
way: It PJv /Gb 771E A&""k/ A-PPRoit-c# a Nv !v ?c' n!� 9
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other: A ragCV1 •
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration #:
Value of Work for this Permit: $
coL,"
Square/Lineal Footage of Work:' 00
***** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scannin
Bond $ (if required) Total Fee Now Due $ ` `1— Qv
ht1__1.& • e`Q
is personally known to me or who has produced
tJr1V`Q.Y li(4Q.YLS1( as
identification.
;stir 1, ,i
A
ifs. Ti
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.
Signa
• •�I '• Authorized Agent
The foregoing instru Pent was acknowledged before
me this 51' day ' ` M 20 ti , by
who
Signature
Company/Utility Agent
'The foregoing instrument was acknowledged before
me this day of , 20 , by
who
is personally known to me or who has produced
as
identification.
NOTARY PU LIC: NOTARY PUBLIC:
Sign: d Sign:
Print: D—'cc Pt'i�� Q Print:
SEAL:
YANADYPRIETO
.t 'a' ;rc MY COMMISSION # FF 214031
• ""' a; EXPIRES: March 25 2019
Bonded Thru Notary Public Undernriters
411111.1,
APPROVED BY:
2017-04-15
SEAL:
*********_**.*********************************
, Public Works Director, or Designee