PW-19-1203Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date:
Location Address Parcel Number
401 NE 103RD ST, Miami Shores, FL 33138 1122310150130
Contacts
Permit NO.: PW -0.5-19-1203
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 11/20/2019
TERRENCE & ELIZABETH WALLACE Owner R2 BUILDERS INC Contractor
401 NE 103 ST, MIAMI SHORES, FL 33138 RODOLFO RODRIGUEZ
Mobile: 6178522747
Business: 3052313113
Description: SIDEWALK FLAGS REPLACEMENT Valuation: $ 2,500.00 Requests:
Inspection sectctiion n
Total Sq Feet: 0.00
Fees
Amount
Education Surcharge
$0.60
Public Works Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$106.10
Payments
Date Paid Amt Paid
Total Fees
$106.10
Credit Card
06/05/2019 $106.10
Amount Due:
$0.00
Building Department Copy
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for E CT ICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVI rti that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating constructs a)dq�i g. Futhermore, I authorize the above named contractor to do the work stated.
Authorized Signatule/Olvner / Applicant / Contractor / Agent Date
June 05, 2019 Page 2 of 2
RE CF 1%4 ED
�-,► Miami Shores Village
MAY 2 4 2019
Public Works Department
(305)795-2210 elC_
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#:TN _C5 19 - (/7,03
Name of Applicant (if utility see below): 17_�
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:_gVI QVC JQ"3ST M1S�Oeac- PL
UTILITY NAME: W Ae
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: 2 (_�LAW106 IwL
Qualifier/Authorized Agent: (49
Address: /0950 "U/ / 3$ Fr A
City: I-VkAkeOVn State: L ZIP: 3 3 x 1
Telephone: 31 I'S Email: 1 w(p _ (2.2 &JI� l wG COA '
State Certification or Registration #: U-,,(, 19136761 Certificate of Competency #:
Requests permission to install (describe work, attach separa a page if necessary) in the adjoining right of
way: S tIQQ W sl lL., CS S 2G ACZ41
Type of Work: ❑ Paving ❑ Utility CEL Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City: State: ZIP:
Telephone: Email:
Registration #:
... • ... .. .. .. ..f ... r. •..w.. '....e...K: wr•..n.L r'4 .4�:ww :., �wlh.. yl
Value of Work for.this Permit:$ *2 %..r�' �� Square/Lineal Footage of Work:.
i
***«*Fees***** a
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning
Bond $ (if required) Total Fee Now Due $
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 I2 A
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 th`e 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 - Signature trio
Ap icant or Authorized Agent C y/Utility Agent
The foregoing instrument was acknowledged before The foregoing instrument was°acknowledged before
me this �2-4— day of ILIA 20 10/ by me his'Z da of Mu 20� by
bi�L� �A1a IlQ t P who who
is personally known to me or who has produced is personally known tom as produced
PL_ as PZ, as
identification. identification.
Sign:
Print: �t )GTr�YtGI U1r1/
SEAL: SEAL: ' u
JUi MA k:iUitwUf.Z
Notary F uLli< Sla)c of Flnridtr
�"� ,��{ Curtuni5sion k GCi I)id91U
My (.fhiun. cxpims M.ir 5.2027
NCfltft rl 1h1nugh IN ::ir,n,!, . ,l,iry bivi. ',3
Sign:
Print:
JULI55A HUU1I6611
Nolory Public - 51,110, of Florida
CUmmlfr}i�on a GG 1H2910
M cofttm, @MPIfus N,a ',, I022
I Tq Nnllondl N,!,
APPROVED BY:
2017-04-15
QA Public Works Director, or Designee