PW-18-3375 (2)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):
VIED
018
Permit#: Pt, ( - 3S14
?(&) tS - 33-1.S
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address: /22-3 Au_ tot Sfrter- lGi( 4)S om- corm- 33 /se
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency # / POO° Z y o
CONTRACTOR,NAME: ' &Ial/t ( "'figK as
Qualifier/Authorized Agent:
Address: $/ D Aim) 18 G• •
City: ,!($ State: ! L ZIP: ?3 / 6 " /
Telephone: Email:
State Certification or Registration #: Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right o
way: expa/it / G% (Jr71 0rAl S tc.)
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:
660
Square/Lineal Footage of Work:
II ***** Fees ***I.*Permit Fee $ 100.00\ clia SO /1(19
Notary $, Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ S�%
4
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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature
Signature
Applicant or Authorized Agent Com /Utility Agent
The foregoin instrument was acknowledged before The foregoing instrument was acknowledge before
me this (JtrYay of /fbt in6J C , 20 /', by me this (o day of M$tg, 20 " , by
erg-14a`f-SPIV GZ who I$% AQ.1J LAM I i-- who
is personally known to me or who has produced
Ft- _Dailf CAS&
identification. SSZZ-SZ0-8 -pj -D
NOTARY PUBLIC
Sign:
Print: f `6'-
SEAL:
as
•""'i, HENRY J. GARCIA, JR.
` 74 Commission # FF 235205
47 Expires May 27, 2019
.fJ,. Balled Thu TroyFat Munroe 800.385419
APPROVED BY:
/p* *******
is personally known to me or who has produced
+f2 -LW-4(62 I-1 CC -S as
identification. LSLJ
NOTARY PUBL
Sign:
Print:
SEAL:
146a>4 6 A-a-C/
, ��►tr t HENRY J. GARCIA, JR.
„, di lot Commission # FF 235205
15, ,.:i frExpires May 27, 2019
, ... ` Banded Thu Troy Fain I mmo* 8003854019
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
4sk
, Public Works Director, or Designee
2017-04-15