REV-18-3433`V 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):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address: /QS-7/1`
Permit#:? (v ���✓
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State:
Telephone: Email: -
State Certification or Registration #:
CONTRACTOR NAME: ( )..
Qualifier/Authorized Ager; ;<
Address:
City: 03 State: r ZIP:
Telephone: Email: # Jv , ( ovws1c'd 6v:�C ive . ces
State Certification or Registration #: (_C-7C 1% 1'il \Certificate of Competency #:
Re Yues permission to instill (ies riberworyC, ?ttach separate page if necessary) in the adjoining right of
way: r I �---
�� P
•f.) 1•••••—Q
ZIP:
Certificate of Competency #
Type of Work: ❑ Paving ❑ Utility , tdSidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
sar,. r,A:,,, :;s=
Value'of Wo'rk''for'tli5`.Pe'rmit
,o-...•�ls
Square/Lineal Footageof Work'
*****Fees*****
Permit Fee $ 100.00 h ....., a,,.. ,....;:
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ GO
sr
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 jurisdictional 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 ttie public works permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection'will be charged.
Signatu
Applicant or Authorized Agent
The foregoinglinstrument was acknowledged before
me thisl day of L) 6 v , 20 ()r , by
who
is,p rqn ly kni^'n t orw�jo/h�as oduced
/r/(�1 / �tJ//Ler! {%i as
identificat , .
Sign: //��
Print: A4)A \.,1( E 4;)
SEAL: J
NOTARY PUBL�C
ti/! ' //
Ut i
ANTHONY E. KILISSANLY, -
14 MY COMMISSION # GG 100640
_ w EXPIRES: May 2, 2021,,
2f,f;°' Bonded Thru Notary Public Underwriters*
APPROVED BY:
2017-04-15
Signature 1
Company/Utility Agent
The foregoing instrument was acknowledged before
me this It day of WC v1 , 20 1426 , by
who
1I grsonally now a or who has produced
/ ! it'd 07() as
identification.
NOTARY PUBLtIIC:
Sign: i144
Print:
SEAL:
•
"" ANTHONY E. KIUSSANLY
�:• MY COMMISSION # GG 100640
_ = EXPIRES: May 2, 2021
„„po Bonded Thru Notary Public Undendtm
a
*********************************
kk \ , Public Works Director, or Designee
N.W. 1 05th STREET
. . ........................ ...................
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•::::::::,.17' ASPHALT PAVEMENT ":::::•••••-•":•-•::- . • .... ' ..
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- ...75 00'( R & M
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REMAINDER
LOT 7
BLOCK 125
E 1/2 OF
LOT 7
BLOCK 125
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-1-() CON11,1 IANCE WITH ALL FEDERAL
lAil ANI) COIN I Y RULES AND REGULATIONS
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