PW-18-2471Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: PW-9=18-2471 Perm!t (VR Number: 631579
issue Date:10/05/2018;
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 12/17/2018
Parcel Number
Project
502 NE 106 ST, Miami Shores , FL 33138
1122310140220
<NONE>
Contacts
MICHAEL DORN
502 NE 106 ST, MIAMI SHORES, FL 331382046
Other: 3057541311
Owner
CHAMPION CONCRETE
JAIME BASILIO
10280 NW 63 TER 105, DORAL, FL 33178
Business: 3052528055
Other: 7864024802
Contractor
MICHAEL DORN
502 NE 106 ST, MIAMI SHORES, FL 331382046
Other: 3057541311
Applicant
Description: REPLACE 5 BROKEN FLAGS / STREET SIDEWALK
Fees
Amount
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
$0.20
$100.00
$3.00
$0.80
$104.00
Valuation: $ 800.00
Total Sq Feet: 100.00
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 strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for LECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AF IDAVI I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating con ructio, and zoning. Futhermore, I authorize the above named contractor to do the work stated.
,J�iri? Mirv
/°ij
Authorized ' ignatu : 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
Name of Applicant (if utility see below): Pt/
Owner off the following described property:
Legal Descri .tion: Lot Block
Permit#:
�G c doz-ai 11J 04-d1,Y41.
Subdivision
Folio #; Z 73 ✓ 0 2-7i3
Address: 02_ sue- l ' `'T Cr44 Z' '!" 3/>)^
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: At I (1)-- "C_
Qualifier/Authorized Agent: J49G/k/"C 0-,� V
Address: .£2-W � ,. b 3 %"I-41 4 /® r-
City: ,i�� _ State: ZIP: 3 /
Telephone: i3 ' 0 Email: 1.70-
State Certi !cation or Registration #: Certificate of Competency #:
)
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
-T d 7 /s/'-Ot
ZIP:
way:
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: $ , 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 $ MC - W
f
Signature
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 perm i s issued. In the
absence of such posted notice, the inspection will not be approved and a reinspe jt'• n will be charged.
*1
c.
C' Signature
Applicant or Authorized Agent
The foregoi instrument was acknowledged before
me this%�t1 day of __ 20 /4, by
,el/,r%t of ®"7 • who
i personally known to me or who has prod ed
0,-a-�3 c/(0 -a
identification.
NOTARY PUBLIC:
Sign:
Print:.r
SEAL:
MAGALY LLAPUR
MY COMMISSION # FF21 ,776
�
e EXPIRES March 25, 201:�
taC7a ,53 FiordallowySeiv.os cWr
APPROVED BY:
4
The forego) n instrument as • acknowledged before
me this 2777 day of 0 /I, by
�7/ ' ? .1 ; / — ' ' who
is personally known to me or who has produced
ompany/Utility Agent
identification.
NOTARY PUBLIC:
Sign: 7e7,r
Print: ,,l4,7Q'G✓P
SEAL:
/0(
as
MAGALY LLAPUR
MY COMMISSION # FF21 776'
o:n. EXPIRES March 25, 2019
007, 398-0.53 FloridallotaryService con,
, 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
1111111 11111 11111 11111 11111 iim mii mi mi
CFN 201EF'C 555196
OR BK 311737 P9 1628 (.1F'9s)
RECORDED II' .'_7,[701:` 14- 4-5,10
r-RI,E't RUVIN! (:i_FF`ii OF COURT
MIANI-DADF COUNTY FLORIDA
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) rt'kC%i1�L C:- o °LAI
hereinafter referred to as the owner of the following described
property (address): 5Cfl /06 5f
Legal Description: Lot Block Subdivision
Folio # /1-723/- v/Li- 027
Requests permission to install (describe work): "gyp (kei`7 e ft!t)t1)
Within the public right of way of (address) .C.12_ Al G /01'
poi Alf 5f oAy'5 /7j
IN CONSIDERATION of the approval of this permit by the Village, th 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 filed in
the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village
(or his fully authorized representative).
Signature VIA 1, U L C (k--_
Owner or Agent
State of Florida
County of Miami Dade /
The foregoin9 instrument was acknowledged before me this 7V4' day of / c?7,1,;' l20 jf, bjr
,t/K/!`/er / a who is personally known to me or who has produced
� irU 3 «6 -dis identification.
NOTARY PUBLIC•
Sign: Jl/%l74e/
Print: / (-7 6/4
uTATh OP VLORUOA, COUNTY OF DAOE
HEREBY CERTIFY t a his is a Prue copy of the
onaina!filed inthis offi P 1 2 2018dayof
AD20
WITNESS my hand and Official Seal.
rARVEY RUVIN, CLERK, of
County Courts
K.,:�• MAGI
MY COMMISSION # FF213776
SIAr ;s#,: EXPIRES March 25. 2019
1407, 398-0• 5.5 FtontlallotaySerme COlr