PW-18-1713Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
P
Parcel Number
Permit NO. PW-6-18-1713
Permit Type: Public Works
Work Classification: Public Works
Permit Status: APPROVED
Issue date: 7/11/2018 Expiration: 10/09/2018
Applicant
386 NE 92 Street
Miami Shores, FL
1132060136420
Block: Lot:
GARY KUTCHER
Owner Information
Address
Phone
Cell
GARY KUTCHER
386 NE 92 ST
MIAMI SHORES FL 33138-3134
Contractor(s)
TECO PEOPLES GAS SYSTEM
Phone Cell Phone
(305)957-3857 (305)970-1783
Valuation:
Total Sq Feet:
$ 1,000.00
0
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Amount
$0.00
$0.00
$0.00
$0.20
$100.00
$3.00
$0.80
Total: $104.00
Pay Date Pay Type
Invoice # PW-6-18-68015
06/22/2018 Check #: 2160
07/11/2018 Check #: 2235
Amt Paid Amt Due
$ 50.00 $ 54.00
$ 54.00 $ 0.00
Available Inspections:
Inspection Type:
Excavation
Review Public Works
Final Public Works
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 ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS Ar IDAV
constructio and
he foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
uthorize the above- . med contractor to do the work stated.
uth riz6d . ignature: 0 ner / Applicant / Contractor / Agent
July 11,2018
Date
Building Depa ment Copy
July 11, 2018 1
RECEIVED
Miami Shores Village JUN 2 2 2018
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d 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):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:
UTILITY NAME: 1 'D
Qualifier/Authorized Agent: lesKs Vc.5 A
Address: A.<.)e
City: r
Telephone: 9S ¥S3- odOG Email:
GA S
State: f'-c . ZIP: 3 33 c S
pu c A- 9, 2 p e e y. c e )04
State Certification or Registration #: Certificate of Competency # e /6 08
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:.
State Certification or Registration #: Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: — Pe-izwc / / — f ,, ~�
,vEe.� Gas S gic v C'c j o t(�',P y�X. 19� (�t " Z18q
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 Scannin i
Bond $ (if required) Total Fee Now Due $ et-1
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 permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature Signature _
Applicant or Authorized Agent
The foregoing instrument was acknowledged before The foregoi
f me this day of , 20 by ,. me this
who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
APPROVED BY: .•
Company/Utility Aft' t
instrument as acknowledged efore
day of ,fin , 20 /6 by
who
is personally
identifica
NOTARY
Sign:
Print:
SEAL:
************************************
n to me or who has produced
as
1''.Sr.. HUBERT NUNEZ
MY COMMISSION # GG 104234
�:-,•,';7 EXPIR _S: September 11, 2021
''''''.• Bonded 'five Notary Public Underwriters
*********
, Public Works Director, or Designee
2017-04-15