PW-18-2464Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: PW-9-18-2464 Permit IVR Number: 631577
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Issue Date: 10/05/2018
Expiration: 12/17/2018
Parcel Number
Project
9410 NE 6 AVE, Miami Shores, FL
1132060140900
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I
Contacts
MANUEL FERNANDEZ
9410 NE 6 AVE, MIAMI SHORES, FL 331382738
Owner
CHAMPION CONCRETE
JAIME BASILIO
10280 NW 63 TER 105, DORAL, FL 33178
Business: 3052528055
Other: 7864024802
Contractor
MANUEL FERNANDEZ
9410 NE 6 AVE, MIAMI SHORES, FL 331382738
Applicant
Description: REPLACE BROKEN STREET SIDEWALK
TO REPLACE EXPIRED
P W 18-82
Fees
Amount
Education Surcharge (Manual)
Permit Fee
Permit Fee (Manual)
Scanning Fee (Manual)
Technology Fee (Manual)
Total:
$0.20
$75.00
$25.00
$3.00
$0.80
$104.00
Valuation: $ 1,000.00
Total Sq Feet: 150.00
Payments
Total Fees
Credit Card
Amount Due:
Amt Paid
$104.00
$104.00
$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 rict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this /aermit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for : ECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFF DAVI ' I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating con•.tructi. and zoning. uthermore, I authorize the above named contractor to do the work stated.
c\ � s / Pe- lam
Authorize. 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 33
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: ?k.)4.) IS —24b4
Name of Applicant (if utility see below): 169-Mik- '% /1'itm-eZ
Owner off the following described property: p
Legal Description: Lot Block Subdivision / �143j190g See,
Folio #; //' 5�Z b - (9l C D A,,� .1
Address: f% 1 %V A) /P%/ �' 5 r 11,-- T 5J5
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME:
(//,V f /tiV fit )
Qualifier/Authorized Agent: b%j //1'-( /13t 4 .��/
Address: /I924'O MI/ 123 7 rfix 4. la)
City: � OC�� State: � � 7�, ! ZIP: 5�'I�'
Telephone: 1. �i - 'on- Email: � � hau ®/,'tty
State Certification or Registration #: Certificate of Competency #: 05,.54:20
Requests permission t install (de cribe work, attach separate pa a if necessa n the adjoining right of
way: Al AO- ! /uOo
Type of Work: ❑ Paving .❑ Utilitydewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration #:
Value of Work for this Permit: $ I BOP
Square/Lineal Footage of.Work: 1 Sv
*****Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 7 ) , C7v
J
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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted a e job
site for the first inspection which occurs seven (7) days after the public works permit is issue n the
absence of such posted notice, the inspection will not be approved and a reinspction will charged.
Signature
Applicant or thorized Agent
The for-goin instrume as ckn I dge fore
me thi / day of � //20 b �, by
who
is personally known to me or who has produced
as
itI/9ivwC * 91z
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
a•uo
OZOE'9t ItdrIV:S3MIdX3
.tLLtO DO # NOISSM O0 AW
SVda00 V1V2! Sol2IVO
Signature
Company/Utility Agent
The foregoing instrument was acknowledged before
e this day�f SL - , 20 `$ , by
cove as; i; p who
t ersonally nown to me p who has produced
ti "t' C*1 4 as
identificatio
Sign:
Print: r' *-3
SEAL:
YANADY PRIETO •
MY COMMISSION # FF 214031
EXPIRES: March 25, 2019
Bonded Thru Notary Public Under triter
APPROVED BY: t lc( , Public Works Director, or Designee
2017-04-15