PW-17-2184Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 3313MUG 2 9
1017.
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RECEIVED
PUBLIC WORKS PERMIT APPLICATION �1
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property �\
Permit#: p�'� - 2 t o _ `
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:
A:cE 9Z S'
UTILITY NAME: `---jZC6 C GP c S s
Qualifier/Authorized Agent:
•Address: .SJ a') A.)w Z ►
City: 0-44 Do2D
Telephone: 9? - 4.i 3 -Uk14. Email:
State Certification or Registration #:
($ A
#t- 44,
State: ZIP: .333 G
ki,t e. a b✓t.t R A y , c c
Certificate of Competency #
CONTRACTOR NAME: /« e-
Qualifier/Authorized Agent: V v- 3 A
Address: Ac''ai N44-) Z 1 .a-vc 4446
State:.
City: ML'k`pc R. a 4--c.‹
Telephone: ('9-SY) ' / 3 62.6 Email:
State Certification or Registration #:
ZIP: -3 33 G' 9
2 Ea N (V-T2"e'a �,�, e rag - c am wt
Certificate of Competency #: 2 - 14
Requests permission to install (descri '•,1; ach separate page if necessary) in the adjoining right of.
way: E.:,OELC) -G :` I
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
El Landscape ❑ Antenna rja Other: 2 s 14
DESIGNER: Architect/Engineer:
Address:
City:
Telephone: Email:
Registration #:
State: ZIP:
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 $ LI ` Co0
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 a d'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.
Si nature y. , ,, � "'illi
� -.
• - g Signature ;
Applicant or Authorized Agent; Company/Utilitynt
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this day of , 20 , by me this „2-.P day of C'J , 20 T 7, by
who -VESas Vas A who
is personally known to me or who has produced is perrsrally known to me or who has produced
as r as
identification.
NOTARY PUBLIC:
Sign: Sign:
identific
NOTA PUB IC:
Print:
SEAL:
Print:
SEAL:
0`'1l4pll;;;..
HUBERTNUNEZ
n MY C 104234
"..;,,,(, ,r, �_ EXPIRES: September 11, 2021
,,,,,„ ••' Bonded Thru Notary Public Underwriters
**********************************
APPROVED BY: \ri'V , Public Works Director, or Designee
2017-04-15