RC-15-931 (2)FEB
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
ANTED
1 •2018
RC IS _g31
Permit#:
kNJ
Name of Applicant (if utility see below): 4,5 -1- (/ e S -44,4 k'
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address: /(i/% 1/E % 5 5'7L!=ee/
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State:
ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of competency #
CONTRACTOR NAME: ` !i .
Qualifier/Aut rued Agent J
Address:a 7 4S W / 72
Agio
FAHt.cJ#.
OUR-1—
City: / 4 r4-o✓l c State: 1-- L ZIP: 3 3 / /0
Telephone: 30 = r2/6-- 7V Email:
State Certification or Registration #: C6C 1567 3G Certificate of Competency #:
Requests permission to insta ,(describe w k, attac separate pa if nece sa j'the adjoinin i t of
way: f�P S d 2 +e4-�' .(/(% s 7i 1 X5A f/ D f P) r.(''W
Type of Work Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration #:
Value of Work for.this Permit:. $,
Permit Fee $ 100.00
__ Fees
Square/Lineal Footage of Work:
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required)
Total Fee Now Due $ Ip4• 00
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 asindicated. 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 O F
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 tfie
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature
Applicantthoriied Agent'
The foregoing instrument as acknowledged before
me.th's/ day of 20 / S! by
LvReoe /I% who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
LAURA JIMENEZ
• : MY COMMISSION # GG155250
„,„67.. EXPIRES October 26, 2021
APPROVED BY:,
Signature
Company/ ity Agent
The foregoing instrumen was acknowledged before
me this /rday of ,20 / P by
it/4X i v ��� / who
is personal) wn-to me or who has produced
as
identification.
NOTARY PUBLIC:
:,�►"' LAURA JIMENEZ
' 'MY ci;MM+SSION a GG155250
, EYP IRES October 26, 2021
**.*********************************
Public Works Director, or Designee
2017-04-15
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) MPs 2 4 f1P5 5 6 C
hereinafter referred to as the owner of the folio ing d scribed
property (address): /0 / % /1% `7 5-5'1,PP e t
Legal Description: Lot Block Subdivision
Folio #
Requests permiss on tp in t II ( cribe work):
A5 /I ,er veal
Within the public rig'ht of wayof (address)
( )
illllllllll iilll IIIII II191IIIII IIIII IIII IIII
C FAN 2018R0I_ 44534
nt BK 30337 F'j 1031 (1P3s)
KARVEY PLJV1'N, CLERK. OF (S-JRT
MIAJ I -DADE .OUNTY FLORIDAD
fee sate -(,>4ee ex,'s
10(7 /vt 9 ffS
IN CONSIDERATION of the approval of this permit by the Village; the owner agrees as follows:
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 the Owner or shall
constitute a lien against the above,described property until paid.
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 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 file
the Public Records of Dade County, Florida by the Village Manag?f,pf,MiarhShores
(or his fully authorized r-presentative). STATE OF FLO X'! ,f the
I HEREBY CERTIFY tha: the foregmnc is a t`4i' an c? wn�'
final on file m this office.
--� �o
RVEY RUVIN, rk of Cir
o ,6dW0' pep clerk
GGR1NE PI
u s acknowledged before me this if day of
Signature
State of Florida
County of Miami Dade
The »/g strf ; fif
NOTARY PUBLIC:
-Sign:
Print: J—a oirc1
ner or Agent
who is personally known to me or who has pr
as identificatrors
SEAL:
,20 /5,by
LAURA JIMENEZ
;'" MY COMMISSION # GG155250
EXPIRES October 26, 2021