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PW-18-2463Miami Shores Village 10050 NE 2 Ave Miami Shores FL 33138 305-795-2204 Location Address Permit,NO.: PW-9- Issue Date:10/05/2018 -2463 Permit IVR Number: 631576 Permit Type: Public Works Work Classification: Public Works Permit Status: Approved Expiration: 12/17/2018 Parcel Number Project 571 NE 94 ST, Miami Shores, FL 33138 1132060140890 <NONE> .. ...... _ 'Contacts SUK KYONG DECOURT 571 NE 94 ST, MIAMI SHORES, FL 331382847 Owner CHAMPION CONCRETE JAIME BASILIO 10280 NW 63 TER 105, DORAL, FL 33178 Business: 3052528055 Other: 7864024802 Contractor Description: REPLACE BROKEN SIDEWALK TO REPLACE EXPIRED PERMIT P W 18-83 Fees Amount Education Surcharge (Manual) Permit Fee Permit Fee (Manual) Scanning Fee (Manual) Technology Fee (Manual) Total: $0.20 $50.00 $50.00 $3.00 $0.80 $104.00 SUK KYONG DECOURT 571 NE 94 ST, MIAMI SHORES, FL 331382847 Applicant Valuation: $ 2,800.00 Total Sq Feet: 400.00 Payments Total Fees Deposit Check # 2973 Credit Card Amt Paid $104.00 $-104.00 $104.00 $104.00 Amount Due: $0.00 Inspection Requests: 305-762-4949 Building Department Copy 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 i -rmit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are required for 4CTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work. ' OWNERS AFF DAVIT certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating con •tructio d zoning. Futhermore, I authorize the above named contractor to do the work stated. /t9 5.1 Authorizes Signature: Owner / Applicant / Contractor / Agent Date October 05, 2018 Page 2 of 4 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 Permit#: Name of Applicant (if utility see below): �7 K' »Vi , j T_Ct3 Owner off the following described property: Legal Descri tion: Lot Block Subdivision Folio #; r . ZjZG2- o ono `,�.�,� Address: 7/Arc se ltij4;dN41'i) 5174105 33/11" ? J \'e, -- 2463 UTILITY NAME: Qualifier/Authorized Agent: Address: City: State: ZIP: Telephone: Email: State Certification or Registration #: Certificate of Competency # 056.50e69( CONTRACTOR NAME: ( a%1Oaii . 11�� Qualifier/Authorized Agent: `//,/-�, 4A5/,t d v Address: /V27 D At) 63 7U City: VOl// State: d/ ZIP: 33 /%% Telephone: " -2 Email:.J; deo i i©O. State Certification or Registration #: Certificate of Competency #: <<D .gs over Requests permission to inst II (describe work, attach separate page if necessa}y) in the adjoining right of way:, tefi'(Acme PW Type of Work: ❑ Paving ❑ Utility 041ewalk ❑ Electric ❑•Irrigation ❑ Landscape ❑ Antenna ❑ Other: DESIGNER: Architect/Engineer: Address: City: State: ZIP: Telephone: ' Email: Registration #: Value of Work for this Permit: $ Z� 00 Square/Lineal Footage of Work: 400 ***** Fees***** Permit Fee $ 100.00 Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ Bond $ (if required) Total Fee Now Due $ y . LD 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. 1 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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to the attachment. Also, a certified copy of the recorded notice of commencement must be p ted at the job site for the first inspection which occurs seven (7) days after the public works permit i Issued. In the absence of such posted notice, the inspection will not be approved and a rein pectin will be charged. Signature Applicant(or Aut !zed Agent The foregoi instrume t w:s ac owledged b 20 7y Say "Y` ' . 'l) who is��rs�, aJl ylc; pryuh as produced hie this dray of identification. - identification ate- ra _ RAULCORPAS ' 1. L RES: August 16, 2020 Signature Comany/Utility Agent The foreg9iRg instrument was knowledged before me this 116 `day of s`f , 20 fS, by Ouwk .-PI-- S,\ t p is so -Ily known to irke or who has produced '11Y.0 1% 'AS as Sign: Print: SEAL: CAR l MY coMm EXPI ... Public Underwriters APPROVED BY: Sign: Print: SEAL: who ;Hr•Py YANADY PRIETO ;,:.. MY COMMISSION ## FF 214031 EXPIRES: March 25, 2019 f;$,•` Bcnded 7;hru N,Wry Pubiic Urderxriters --.:a:.xs ****t**************************************** I4,V k) 1t) , Public Works Director, or Designee • 2017-04-15