PW-18-3047Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: PW-10-18-3047 Permit IVR Number: 100290
Issue Date: 10/05/2018
Parcel Number
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 04/01/2019
1499 NE 104TH ST, Miami Shores, FL 33138
1122320320110
Contacts
PATRICK LONGMAN
1499 NE 104 ST, MIAMI, FL 331382663
Other: 3056773046
Owner
CHAMPION CONCRETE
JAIME BASILIO
10280 NW 63 TER 105, DORAL, FL 33178
Business: 3052528055
Other: 7864024802
Contractor
Description: PAVERS TO REPLACE DS 18-462
Fees
Amount
Public Works Permit Fee
Total:
$50.00
$50.00
Valuation:
Total Sq Feet:
$ 100.00
0.00
Payments
Total Fees
Credit Card
Amount Due:
Amt Paid
$50.00
$50.00
$0.00
Inspection Requests:
305-762=4949
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 AFFIDA ' IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating c• _u g ion and zoning. Futhermore, I authorize the above named contractor to do the work stated.
4(d e-fi
Authoriz 'd Signature: Owner / Applicant / Contractor / Agent Date
October 05, 2018
Page 2 of 4
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
RECEIVED
OCT 032018
Permit#: 471.) 3 ok-i
Name of Applicant (if utility see below): A -Ina— 641/44II
po
Owner off the following described property:
Legal Description: Lot Block
Folio #; l— Z1-32.- 092_ 010
Address: ► '--(4 cj `i S'1
Subdivision
1 t14n shy
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: Of-r-AMIYAI
Qualifier/Authorized Agent: -t 5iAJ, r7:
Address: 10 i" () P0 (3 -7 A-- ) 0j
City: 1 v State:
Telephone: 0 'j Email:
State Certification or Registration #:
ZIP: 3517c
Certificate of Competency #: C60.5-- 00lf
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: -t® r_47 LO( ew t5— LCo L,1
Type of Work: ❑ Paving. ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address: -
City: State:
Telephone:
Registration #:
u r - u.v .w • s s+., ..
Value ofWork foi'this {permit $. y ` :s
Permit Fees 100.00 ��fY
Notary $ Training/Education $ 0.20
Bond $ (if required)
Email:
ZIP:
44.1
Square%Lineal FootageofWork +. a
Gr:, Uy
Fees *****, , ',r
Technology Fee $ 0.80 Scanning $
Total Fee Now Due $ �O•'
Bonding Company's Name (if applicable):
Bonding Company's Address:
City: State: ZIP:
Applicatioh 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 notic of commencement must be'posted at the job
site for the first inspection which occurs seven (7) days after the'public works permit is • ued. In the
absence of;such.pp�osted notice, the inspection will not be approved and a reirispection ill b'e charged.
Signature Signature
pplicant or,Authorized Agent y i . . , Company/Utility Agent
The foregoing instrum= 't wasacknowledged 'efore`, The foregoing instrumgqt wasacknowledged before
rp,e this 8( day of • _J.1,• 20 , by m} thisf - day of ye.ap e- , 20 1 R , by
VairfiGk Leq•JC mi1. who J(,�i (y' Pc . P S; 1,; b who
is personally known to ni"6 oryvho has produced is�ersonally known tq me or who has produced
��— as ,, •�(;,/.Q (' S LA e.Q. n — as
identification. identification.
OTARY PIC:
ign:
OTARY P
1
Print: '"`CQJc • 1N. i:M Print: I"ICI�V� •
SEAL: SEAL:
�s
r d , MARVAM.YAWNS
4 MY COMMISSION II FF 203592
EXPIRES: February 25, 2019
Bonded Tan Notary Pubic Undeardea s
APPROVED BY:-
+uu
MARVA M. WILLUMS
MY COMMISSION # FF 203592
EXPIRES: February 25, 2019
Bolded TAN Nogry Pubic Undeiwd*en
*********.******** **************************
, Public Works Director, or Designee
i
2017-04-15