PW-19-1122Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 05/21/2019
Location Address Parcel Number
990 NE 97TH ST, Miami Shores, FL 33138 1132060143150
Contacts
Permit NO.: Piili-05-19-1122
Permit Type: Public Works
Work Class#ication: Public Works
Permit status: Approved
Expiration: 11/18/2019
WILLIAM MERCER Owner TECO PEOPLES GAS SYSTEM Contractor
990 NE 97 ST, MIAMI SHORES, FL 331382569 JESUS VEGA
15779 West Dixie Hwy, North Miami Beach, FL 33162
Business:
305957385777247
Other: 3059701783
Inspection Requests:_
Description: TO INSTALL A NEW GAS SERVICE LINE (3/4" Valuation: $ 1,000.00
PLASTIC) BY DIRECTIONAL BORE
- 499
to replace expired permit PW -9-18-2486 Total Sq Feet: 2.00
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
Check # 3464
05/21/2019 $105.70
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 AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning. Futhermore, I authorize the above name n actor to do the work
a� a�o /19
Authorized Signature: Owner / Applicant / Contractor �/� Agent
May 21, 2019
Date
Page 2 of 2
s � BI
Miami Shores Village MAY
Public Works Department
(305)795-2210 $Y:
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#: VVJ - I I' I L
Name of Applicant (if utility see below): TECO PEOPLES GAS
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address: 99D _J_r 5 -7 s�
UTILITY NAME: TECO PEOPLES GAS
Qualifier/Authorized Agent: JESUS VEGA
Address: 5101 NW 21 AVE.
City: FT. LAUDERDALE State: FL ZIP: 33309
Telephone: 954-453-0806 Email: MCABRERA@TECOENERGY.COM
State Certification or Registration #: E1608 Certificate of Competency # G i
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: TO INSTALLrA NEW GAS SERVICE LINE (1 1/4" PLASTIC) BY DIRECTIONAL BORE
C/VC�A`G !� 7 / 9 2- b
Type of Work: ❑ Paving ❑■ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ , Other:
DESIGNER: Architect/Engineer:
Address:
Citv:
Telephone:
Registration #:
State:
Email:
Value of Work for this Permit: $1000
Permit Fee $ 100.00
Notary $
Bond $
ZIP:
Square/Lineal Footage of Work:
*****Fees*****
-Train ing/Education $ 0.20 Technology Fee $ 0.80 Scanning $
(if required) Total Fee Now Due $
19
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 approved and a reinspection will be charged.
Signature
Applicant or Authorized Agent
The foregoing instrument was acknowledged before
me this day of 20, by
who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Signature V9� UI 1_
Company/Utiki Agent
The foregoininstrument was acknowledged before
me this day of 1 zQ- 20J J_ , by
who
personally known torhe or who has produced
as
id
NOTARY
Sign:Si •
HUBERT NUNEZ
Print: Print: ?` MY COMMISSION # GG 104234
SEAL: SEAL: z EXPIRES: Soptembor 11, 2021
Bonded Thru Notary Public Undorwrilera
********************************************
APPROVED BY: A Public Works Director, or Designee
2017-04-15