PW-18-3386Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Issue Date :11/08/2018
Parcel Number
Permit NO.: PW-11-18-3386
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 05/06/2019
1201 NE 96TH ST, Miami Shores, FL 33138
1132060143830
Contacts
TRACY FRANKLIN ZAZADZE
1201 NE 96 ST, MIAMI SHORES, FL 33138
Other: 3057902765
Owner
HOME INTERIOR SERVICES AND
INVESTMENT INC
JUAN PABLO BETANCOURT
1690 W 38 PL B1, HIALEAH, FL 33012
Business: 3053288590
Other: 7865978093
Contractor
Description: REPAIR SIDEWALK
Fees
Amount
Education Surcharge
Public Works Permit Fee
Scanning Fee
Technology Fee
$0.60
$100.00
$9.00
$2.50
Total: $112.10
Valuation: $ 2,500.00
Total Sq Feet: 250.00
Inspection Requests:
305-762-4949'
Payments
Total Fees
Credit Card
Credit Card
Amount Due:
Date Paid
11/08/2018
11/07/2018
Amt Paid
$112.10
$62.10
$50.00
$0.00
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 ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning. Futhermore, I authorize the above named contr..tnr to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / A• - Date
November 08, 2018 Page 2 of 2
\\ \30
Miami Shores Village
Jar `�� Public Works Department
�J (305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores, FL 33138
RECRTI 71-L7 t;
072018
BY
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):
Owner off the following described property:
Legal Description: Lot
PoI
2 `t3c&c
Block Subdivision
Folio#; 11— 30- , — 3 30
Address:
Permit#:
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
Certificate of,Competency #
State Certification or Registration #:
CONTRACTOR NAME'""—'JO tt& { i in, 5—��-u) r .
Qualifier/Authorized Agent: �v �. 44vw, •»- - r
Address: 1FI C 3 b II` 6 tc.cc 1
City: _11,• .... State: r , ZIP: "--2-3 v 1 .?.-
Telephone: `1'59'1€2a73 Email: jti Nen 1h 142,,v SQ,n„"�sc . rto+ •
State Certification or Registration #:C( 1LS13bb . Certificate of Competency #:
Requests permission to install (describe work, attach separate page if.necessary) in the adjoining right of
way: 1 pcuiv- S (c�t ctQG
Type of Work: ❑ Paving ❑ Utility
❑ Landscape ❑ Antenna
Sidewalk ❑ -Electric,
Other:
Irrigation
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone:
Registration•#:
Value ofWorkfor this=Permit: yr$ ~200
Square/Lineal Footage of V1'ork:
*****Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ • 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.'t certify that no work or installation has commenced prior to the issuance of a
a
permit and that all work will be performed to meet the standards of all laws, regulation construction in
this jurisdiction. Iunderstand 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.
x
"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
attachment. Also, a
site for the first insp
absence of such po
Signature
e
certif opy of the
• on which occur
ed notic-,the •
e delivered to the person whose property is subject to the
ecorded notice of commencement must be posted at the job
seven (7)days after the public works permit is issued. In the
pection will not be approved and a reinspection will be charged.
A or A thorized Agent'
The foregoing instr t was acknowledge efore
me this S day of: �1QV , 20 , by
who
pypduced
as
is pers ally knownto
identification.
UB
Print:
SEAL
or who has
MAHARAI K. G• r L
MY COMMISSION# 2044602
EXPIRES: November
Bonded Thru Notary Public Underwriters
Signature
Co pany/Utility Agent
The foregoing i tru a t•was afknowledged before
me t is day of- �)tJv4 t _- , 20 I �' , by
c� �'^ '� - j¢12,v1 c.�J� who
is person Iy known to me or who has produced
�L
identificaon.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
as
ate"" " Notary Public State of Florida
• Dennis Lefton
o* My Commission,GG 073635
nor .o. Expires 02/15/2021
*********** **********************************
APPROVED BY:, \` \' \ 1 , Public Works Director, or Designee
2017-04-15
&-seo
Miami Shores Village
APPROVED
BY
DATE
ZONING DEPT
BLDG DEPT
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LOT 17 uyr IF
B1.00IC 83 I L3LOCK 83
GAR AGE
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0
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TWO STORY
C.B.S. RESIDENCE
# 1201
P.P. ELEV.- 13.28'
12(15'
17,80'
'27' ASPHALT PAVEMENT
. 96th STREET::::
REMAINDER
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