DS-18-462 (3)Name of Applicant (if utility see below):
Miami Shores Village
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#: � 1 fr."—�1 'M
/1nm_ Ds i r- k Z
-//77/0d/ I lit) bAtof
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #; 22- -- 032 -- 0'//
Address: 7Y iy NZ (0'f Sir ! l47AA,%( 511 , 337
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: (/ / /. t/ (-�I w)'� eilittaQualifier/Authorized Agent: tit
�i./�j Address: /OZio t�
City: - DD.4 State: ILL ZIP: 33 /'73/
Telephone: Email:=
State Certification or Registration #: Certificate of Competency #: C6O5 547c4
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: 70AVA5 AT / N‘9 kg- /C2K 5% J` X/ 5/7D7tco
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrig
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
NCEL LEt
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 Scannin4
Bond $ (if required) Total Fee Now Due $
a•1
Bonding Company's Name (if applicable):
Bonding Company's Address:
City: State: ZIP:
r -
.Application is' hereby made to obtain apublic works permit to do the work in the right of way and
installations es 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 acondition 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'c n truction lien law brochure will be delivered to the person whose property is subject to the
%et 'watt chment. Also, a certified copy of the recorded notice of commencement must' be poste at the job
,- site for the first inspection which occurs seven (7) days after the public works'permit is is d. In the
` absence of such posted notice, the inspection will not be approved and a reinspection be charged.
Signature
Signature
Applicant or Atfthorized Agent ,— _ z Compar(y/Utility Agent
�- c �,. - t � - ��. , -tier-r,
The foregoing instrument was acknowledged before -The foregoing instrument was acknowledged"before
/r/61/y20 /8, by me this day of, CPl/z. "" /, 20 /6 by
."-1 /7 who 5Q/i 'e %�¢,-//' who
r who has produced is personally knowp tome or who has produced
O� h as /Jt'/i '77a'/fy �2%4G�'2 as
• dentification
me this? , day of ,40
,oi/g/ 4977
is personallyk i�1wn to me
h A L* 4',fir
identification:
NOTARY PUBLIC:
Sign: ;/`
•
61-gA
MAGALY LLAPUR
MY COMMISSION # FF21'776
EXPIRES March 25, 2019
Cam%'
r t407 , 399-0' 53 floridallota'yServa;c. corn
APPROVED BY:
NOTARY PUBLIC:
Sign: 2/
Print: rl/ry9�r'
v/
SEAL.
•••eN. MAGALY LLAPUR
MY. COMMISSION # FF21.,776 j
;or
EXPIRES March 25. 2019
.407, 398-0' 53 Fbridalloaa yServicaanr
***************************
Ta 1 , Public Works Director, or Designee'
2017-04-15