PW-18-861Miami Shores Village
10050 N.E. 2nd Avenue NE
Miami Shores, FL 33138-0000
Phone: (305)795-2204
Project Address
Permit
Parcel Number
Issue Date: 4/17/2018
Permit NO. PW-4-18-861
Permit Type: Public Works
Work Classification: Public Works.
Permit Status: APPROVED
Expiration: 07/16/2018
Applicant
975 NE 92 Street
Miami Shores, FL
1132060060030
Block: Lot:
MARCIA PAGE
Owner Information
Address
Phone
CeII
MARCIA PAGE
975 NE 92 Street
MIAMI SHORES FL 33138-
975 NE 92 Street
MIAMI SHORES FL 33138-
Contractor(s)
CHAMPION CONCRETE
Phone CeII Phone
(305)252-8055 (786)402-4802
Valuation:
$ 6,000.00
Total Sq Feet: 1000
Scanning: 1
Fees Due
CCF
DBPR Fee
DCA Fee
Education Surcharge
Permit Fee
Scanning Fee
Technology Fee
Total:
Amount
$o.00
$o.00
$0.00
$0.20
$100.00
$3.00
$0.80
$104.00
Pay Date Pay Type
Invoice # PW-4-18-67023
04/03/2018 Check #: 2828
04/17/2018 Credit Card
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 AFFIDAVIT: certi t all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction and zon, I authorize the above -named contractor to do the work stated.
Authori •d Signature:
April 17, 2018
er / Applicant / Contractor / Agent Date
Buildin r; Department Copy
April 17, 2018 1
-+I
Miami Shores Village
Public Works Department BY.
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores, FL 33138
AP03 i18
A
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: t7S (9
7v) (8 -96
Name of Applicant (if utility see below): ii4/2 cM-- �ji16r,
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #; //- 32G% - 006 - 003 O
Address: cl7S ,{) 4/2- St7o/71->J fl_ 33 /33-
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: (/.4/L-1/aL. ‘ttil. 7-C
Qualifier/Authorized Agent: - /I�/Mt /SA.V4-1 !3
Address: /CZJ'O /WO 63 7-C,crt.
City: 'G4' l
Telephone: ,34-'vcf Email:.
State Certification or Registration #: Certificate of Competency #4 -tz5 6S4704'i-5
State:
ZIP: 3317P
Requests permJsion to install (describe work, attach separate page if necessary) in the adjoining right of
way: (a/V +RAaAe--11 '-40S 24/
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalks�❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other: 62/vOIffie_ 1//I1kat
DESIGNER: Architect/Engineer:
Address:
City: t It:o , State: ZIP:
Telephone: ` "•Email.,.
Registration #:
Value of Work for this Permit: $ GOaD 0c) Square/Lineal Footage of Work: (
***** Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scannin
Bond $ (if required) Total Fee Now Due
,is si5It,
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.
< C\ c- *% lam. .v\.' . �\ � k"
"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 gfter the public works permit • issued. In the
absence of such posted notice, the inspection will not be approved and a reinspecti.j will be charged.
Signature
Applicant or A orized Agent Company/Utility Agent
The forego' : instrumen vitas acknowledged before The foreptis4g instrument w s acknowledged before
methis .L day of ioroGig , 20 , by me this ay of , 201 , by
(.76.. 1 who '3720rrlii_ A) 0 who
is personally known to me or who has produced is person kit n e or who has produced
mac- p2ill2fL as
as
identification.
NOTARY PU
Sign:
Print:
SEAL:
APPROVED BY:
Signature
identification.
NOTARY PUBLIC
///bPrint: :::•:..,...,\‘‘,\::::1::1::#1°//6,:i....0,01...s... .SEAL: t'S
9
CO , `4 �ti'Z. e r
••mil , y„ 4•\.� � `� S:. h) `n �i
�11411 111111111111
N, Public Works Director, or Designee
Sign:
2017-04-15
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
111111111111111111111111111111111111111111111
psi'. F Fed 2 `=r 13 R r=r =I 9 7 7 0 6
OR BK 30866 Ps 4036 (1 Ps s i
RECORDED 02i16/018 1.3:32: 6
HfRVEY RUVIN, CLERK OF COURT
MI EMI—D DE COUNTY FLORIDA
S IATE Of COUNTY OF DARE
1 i ERE+TY CERTIFY f FLORIDA_at this is a t:u•s copy plc the .
COVENANT OF CONSTRUCTION WI HIN IGHT OF WAY°o-'g''�'''`i1a`�"'tiisoffice OP' .,_aavof
Whereas, (owner)tiR1 aia 1/ ',4 6 .SER l S Iry j r J ri_..
If..R�LI` J`J tiEf' '� ',lid I Cubits
hereinafter referred to as the owner of he following described ,,�-
property (address): Q75 N� c 2 h ►ottf, 5l -ti° r►! - , 4i/'110 r� C..
_ J� -
Legal Description: Lot BpI ck Subdivision
Folio # %% 52a- 006 ^003 )
Requests permission to install (describe work): (p l''7e .-J4N. beidv
cot,
Within the public right of way of (addresq)
g7�A)5 q 5) ONg ,T,',) 3 /-
IN CONSIDERATION of the approval of this permit by the Village, the o ner agrees as follows:
1. To maintain and repair, when necessary, the above -mentioned item(s) installed within the
dedicated right of way. If it becomes necessary for Miami Shores Village or Dade County to
make repairs or maintain said items within public right of way including restoration of street by
reason of the Owner's failure to do so, such expense shall be paid by the Owner or shall
constitute a lien against the above described property until paid.
2. The owner does hereby agree to indemnify and hold Miami Shores Village or Dade County
harmless from any and all liability, which may rise by virtue of permitting the installation of
these items within the public right of way.
3. The Owner does hereby agree to remove or relocate their facilities at their own expense,
within 60 days notice by the Village to do so. Failure to comply with this notice will result in the
Village causing the item(s) to be removed and a lien being placed on the property and/or
assessed against the Owner for all costs incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running
with the land and shall remain in full force and effect and be binding on the undersigned, their
heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in
the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village
(or his fully authorized representative).
Signature
Owner or Agent
State of Florida
County of Miami Dade
The foregoing instrument
4it►✓e1S (ilLehSas
NOTARY PUBLIC:
Sign:
Print:
c-/Aiww- /04/6
was acknowledged before me this e9day of ?' , 20 / , by
who is personally known to me or who has produced
identification.
6S)(IG
ektr
SEAI1
V
,o",R,,,,,,,, . BASILIC BELTRE
=t Notary Public • State of Florida
• I Commission M GG 005313
My Comm. Expires Jun 23, 2020
• Bonded timouq t NMiofal Notary Assn. 0
1