PW-19-320Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 03/27/2019
Location Address Parcel Number
25 NE 108 ST, Miami Shores, FL 33161 1121360110430
Contacts
Permit NO.: PW-03-19-620
Permit Type: Public Works
Work Classification. Public Works
Permit Status: Approved
Expiration: 09/18/2019
Owner Applicant
25 NE 108 ST, MIAMI SHORES, FL 33161 25 NE 108 ST, MIAMI SHORES, FL 33161
MIAMI SKYLINE CONSTRUCTION SERVICE Contractor
CORP
CLAUDIO S RODRIGUEZ
12864 Biscayne Boulevard #176, North Miami , FL 33181
Business: 3052162224
Inspection
Description: REPAIR ASPHALT IN BACK ALLEY OF PORPERTY Valuation: $ 500.00 Requests:
4949
TotalSq Feet: 20.00
Fees
Amount
Education Surcharge
$0.20
Public Works Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$105.70
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$105.70
Credit Card
03/22/2019 $50.00
Credit Card
03/27/2019 $55.70
Amount Due:
$0.00
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 AFFIDAVJ I.certi that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating con ton and g. Futhermore, I authorize the above named contractor to do the work stated.
7 r�:)/ I ,/ Q,
Authorized Signa / Applicant / Contractor / Agent
March 27, 2019 Page 2 of 2
4-. 1����C1 RECEI
l � VED
—�* Miami Shores Village MAR 2 2 2019
Public Works Department BY
:-Qq
(305)795-2230
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#: QS�,�.�`
Ca 2-
Name of Applicant (if utility see below):.
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: .,._.,..,_,,,....,.,, _ State: ZIP:
Telephone:mil:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: c� K-
Qualifier/Authorized Agent: v-<<eue
Address: 20 QF, 12
City: State: �71 o'r ; CA
Telephone: - Email: b e .>
State Certification or Registration #: CertificatO
-rCnse Z-CoO�'vU
Requests permission to install (describe work, attach separate page it
way:_ ZpPe--%yr Aso1'Q1 i o bacl%- C-'kte Ll O
ZIP: I G (
i'l Ir ir;ntil r ( ot-f
of Competency #:
in the adjoining right of
Type of Work: E Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State: ZIP:
Email:
Value of Work for this Permit: $ 5 �Q = Square/Lineal Footage of Work: /
***** Fees*****
Permit Fee $100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 'S • :�)—
I
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.
"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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such posted notice, t spection will not be approved and a reinspection will be charged.
gnature Signature
Applicant or AuthorizedAgent Company/Utility Agent
The forepo}'og instrument was cknowledged efore The foregoing instrument was acknowledged before
me this OlJ day of 20 , by me this day of 20, by
,
s1.'� cte.�eZ who who
is �rcenally known o me or who as produced is personally known to me or who has produced
as as
identification. identification.
NOTA U
NOTARY PUBLIC:
Sign^-
Sign:
`��5
Print: v \� G> -
Print:
SEAL:
(MMlg$ION # CG 174378
• = EXPIRES: JUM610, 2022
hru
APPROVED BY:
Public Works Director, or Designee
2017-04-15