PW-18-195Permit NO. PW -1-18-195
Miami Shores Village Permit Type: Public Works
` 10050 N.E. 2nd Avenue NWP't
Miami Shores, FL 33138-0000 ertill Work Classification. Public Works
eFN-�.• Phone: (305)795-2204
Permit Status: APPROVED
�ORtDA
Issue Datot 1131.12018 1 Expiration: 05/01/2018
Project Address Parcel Number Aoolicant
150 NW 99 Street 1131010240031
Miami Shores, FL 33150- Block: Lot: VICTOR M. DE JESUS MELENDE
Owner Information Address Phone Cell
VICTOR M. DE JESUS MELENDEZ 150 NW 99 Street (786)236-3548
MIAMI SHORES FL 33150-
150 NW 99 Street
MIAMI SHORES FL 33150-
Contractor(s) Phone Cell Phone
CAIBAI CONSTRUCTION LLC (786)229-2770 (786)470-4207
ing: 1
Fees Due
Amount
CCF
$0.00
DBPR Fee
$0.00
DCA Fee
$0.00
Education Surcharge
$0.20
Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$0.80
Total:
$104.00
Valuation: $ 1,000.00
Total Sq Feet: 1000
Pay Date Pay Type Amt Paid Amt Due
Invoice # PW -1-18-66226
01/31/2018 Credit Card $ 104.00 $ 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 AFFIDAVI I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
construction andore, I authorize the above-named contractor to do the work stated.
k
January 31, 2018
Authorizedi a ure: Owner / Applicant / Contractor / Agent
Building Department Copy
January 31, 2018 1
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
Name of Applicant (if utility see below): �� \' V' —ox— --stS"
2.0 2018
Permit#.- D 1 ( J
Owner off the following described property:
Legal Description: Lot Block Subdivision ho z", &,A .S'uia
Folio #; 1 � — 3101 _D -W4 _da31
Address: 1 S� JJ %.J 9 I %,:c,v v S t►-c.s , IF L 33 i Sa
UTILITY NAME:
Qualifier/Authorized Agent:
Address: _
City:
Telephone:
State Certification or Registration #:
Email:
State:
ZIP:
Certificate of Competency #
CONTRACTOR NAME: 04-; 0.4/ 7-
Qualifier/Authorized
Qualifier/Authorized Agent: ZrZoi ZajCo
Address: _ I&A
City: JI 0'II State: ZIP: X31 /vim
Telephone: 2Z- Z72 O Email: /Bd/CoA&riz-a /D �'4rlAico
State Certification or Registration #:4�6 GyS80&S- Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: of 49,gc r rt,l
Type of Work: ❑ Paving ❑ Utility
❑ Landscape ❑ Antenna
DESIGNER: Architect/Engineer:
Address:
City:
Telephone: _
Registration #:
State:
Email:
❑ Sidewalk ❑ Electric ❑ Irrigation
[Other: 00-66 oma✓ Sc,✓oL tL
ZIP:
n'
Value of Work for this Permit: .$ elt,4i ry !°� Square/Lineal Footage of Work: // vvp g)•
**** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ ' (if required) Total Fee Now Due $ ( OY
V
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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such posted notice, the inspection will not be approvedtiand a reinspecj4op will be charged.
Signature I \
Appli ant thorized Agent
The foregoing instrumt was acknowledged before
me this *2-3_ day of JLg=:::�$ 20 19 , by
IMP- t�41,ti IE5US I-'kENW--� who
personally known to me or who has produced
bpA mr— C.l C.F NSE as
identification.
Signature
Cor4kafil/Utility Agent
The foregoing'ifistrument was acknowledged before
me this 3 '\ day o 20 lea , by
\aSr✓ L�SC� who
is personally known to me or who has produced
as
identification.
NOTARY P LIC: NOTARY PUB IC:
Sign: Sign:
Print: JI NbIA Print: .
SEAL:+ w^rlrw vtir- SEAL:
0
p' YpVNotary Public State of Florida
Sintlia Alvarez
a Iv;}' 0umm ssion FF 156750 Notary Publk Stabs bf Fbdda
OF f`pQ� Expires 09/03/2018 Ana M Ramabo
My co.,11. on GG 101009
of �► �s 06/0312021
** **** * ******* **************************
APPROVED BY: f Z� Public Works Director, or Designee
2017-04-15
CAIBAI CONSTRUCTION LLC
Date: ( f 31(Z41�'•
State of
County of AAyiA-Y r�
Before me this day personally appeared LV��1jD"5�t who, being duly sworn, deposes and
says:
That he or she will be the only person working on the project located at: /,0 VCJ F 7-�4 V-,
Sworn to (or affirmed) and subscribed before me this 3_�_ day of 20�by
Personally know
OR Produced Identification
Type of Identification Produced
Notary StaEe of Florida
Rwn ,
� Ana M RameMo
MY commisdon GG 101000
a Expkn 05ro3=t
Print, Type or Stamp Name of Notary
Miami shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
Notice to Owner - Workers' Compensation Insurance Exemption
Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05
allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to
obtaining a building permit. Pursuant to the Florida Division of Workers' Compensation Employer Facts Brochure:
An employer in the construction industry who employs one or more part-time or full-time
employees, including the owner, must obtain workers' compensation coverage. Corporate officers
or members of a limited liability company (LLC) in the construction industry may elect to be
exempt if:
1. The officer owns at least 10 percent of the stock of the corporation, or in the case of
an LLC, a statement attesting to the minimum 10 percent ownership;
2. The officer is listed as an officer of the corporation in the records of the Florida
Department of State, Division of Corporations; and
3. The corporation is registered and listed as active with the Florida Department of
State, Division of Corporations.
No more than three corporate officers per corporation or limited liability company members are
allowed to be exempt. Construction exemptions are valid for a period of two years or until a
voluntary revocation is filed or the exemption is revoked by the Division.
Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use
day labor, part-time employees or subcontractors for your project. The contractor has provided an affidavit stating that he or she will
be the only person allowed to work on your project. In these circumstances, Miami Shores Village does not require verification of
workers' compensation insurance coverage from the contractor's company for day labor, part-time employees or subcontractors.
BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS
CONTENTS.
Signature: a)
Owner
State of Florida
County of Miami -Dade
The foregoing was acknowledge before me this �31— day of �j� )%� (, 20 1
By 1 CZt3,-- - _PE- _3'LSUSwfio is personally known to me or has produced
(� as identification.
Notary:
SEAL: o6pgy P% Notary Public State of Florida
Sindia Alvarez
o� My Commission FF 156750
o� Expires 0910312018
_
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OR: EX —10818 F3 46?6 t iPsis i
R!itilIhb i LE:R4,. OF COUF,
11lAM DODE COLNTY> FLORTIsa
COVENANT OF CO STRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) \ �cb-1-- Y-Lus
hereinafter referred to as the owner of the following described
property (address): 1.SD k)w 9 +` -5j--i
Legal Description: Lot Block Subdivision
Folio # 1\-3\01 —o2�,k— OC�31
Requests permission to install (describe work): /rg
Within the public right of way of (address) /Sa .V0 iffy S�4e_-f
i216,K( S46_ -S-, x 3,?ice
IN CONSIDERATION of the approval of this permit by the Village, the owner 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 authorizd r ntative).
Signature
O e or Agent
State of Florida
County of Miami Dade
The foregoing instrument was ackr ledged before me this 2-3 day ofJ UQ-2� , 20 (e by
�I icy -uE Esv S -It"Mo Is personally known to me or who has produced
1'�--r5P_fw,� u c�.K►SQ- as identification. -
NOTARY BLIC:
Sign:
Print: cuc-.2_� SEAL:
tiT11TR OF FLOROA, COUNTY CE DADS
I HEREBY CER77FY that this is a true Capt' of dre
ani fated ie Kris ofte onday of
SAN 2 o toi�AD20
f a1�`S�►nY d ' 'al Seat
ref Ckwit and Ccamoy Carats
r7i — — D.C.
b v PLL, Notary Public State of Florida
? ;= India Alvarez
i:iy Commission FF 156750
9�oF 11 Expires 0910312018