REV-18-3133Miami 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
Permit#: 'PZV
Name of Applicant (if utility see below): LI80/ . Proms LL_t-_ .
Owner off the following describ 'gd property: l ,�
Legal Description: Lot 3 )`'C Block � _ Subdivision r"I mmi Sd�M6 See,. 10-7,0
Folio#;_//- ,.'r
Address: 'l bbl IVF 2 P -60A l/� �"/1 AM, 5T41R,FS �l • 3 � 13 g
UTILITY NAME: VIA,
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
State:
ZIP.
Certificate of Competency #
CONTRACTOR NAME: JC, 4 Ae- Gz /ATVs 45:,roi3P.
Qualifier/Authorized Agent:--Jo^p! to G1�o
Address: '-7-74) >W ZZ
City: tfl *,"I State: Ft- ZIP:
Telephone: 2-31,111 Email: Jc O �"ad •Gc
State Certification or Registration #: G G O Certificate f Competency #:
Requests
rp-ermission o install (describe work, attach separate page if necessary) in the adjoining right of
way: M��/��EP6A�E s% $ SrCo"e_p6M_-M_AGM
A eKES51 rpt UT% E9A7 LJ) M -em &W7 S C�_D F-XVST. >ETAt L S Ps4Cg-_5 211—Z1'zPVE47 SS r
Type of Work: ❑ Paving ❑ Utility X Sidewalk ❑ Electric ❑ Irrigation
DESIGNER: Arc
Address: �14
City:
Telephone:
Registration #:
❑ Landscape ❑ Antenna' ❑ Other:
ite;t/Engineer: G NI n/G/n�i �i�l/7o G jS (20, -
Value of Work for this Permit: $ 2,"V � Square/lineal Footage of Work:
2g55F
***** Fees*****
Permit Fee $ 100.00 -;�! . 50
Notary $ �)S Training/Education $ 0.20 Technology Fee $4)86• Scanning $,5`1
Bond $ 0' _ (if required) Total Fee Now Due $
Bonding Company's Name (if applicable):
Bonding Company's Address: N ,Ar
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 644J4P ;
Applicant or Authorized Agent
The foregoing instrume wa ack owledg efore
me this � day of CM 2 % by
who
is personally known to me or who has produced
Signature
Theforeg(
me this /
who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Sign:
int: Lilian Pascual
AL: xsWiLJ/ 13
EXPIRES: May 31, 2022
Bonded Thru Awm Notary
APPROVED BY:CAL .-1:Z Public Works Director, or Designee
2017-04-15
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
Whereas, (owner) x'801 PAP.,. -K LL,6—
hereinafter referred to as the owner of the following described
property (address): 1 N, �/E . Mc. Ll 3313 S
Legal Description: Lot !3 / lock 32 Subdivision M/Am, iHyt SEG I. P� ��• 70
Folio # /1-.3 Ula -4300
Requests permission to install (describe work):FEinV ✓� fl f PU4CE f/- 57 of G /con<<z&74-7
5/ rpeW -tr_ w i rpf CoNNt?_T Ag- w2® P. ,4rmPS
OR BK 31145 Pss 3216-3217 (2P -3s)
r`c_; O4.,`,cry !. ` ;"18
Within the public right of way of (address) 2.11- �9'S AT*6y7- M,,kA , shove& 3;3 13s .
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 authorized representative).
Signature
Owner or Agent
State of Florida
County of Miami Dade
The foregoing }.�stru "rit,was acknowledged before. -me this, l day f`M ; 20 , by�°r
as who is personally known to me or who has produced
rc``e CL E
SEAL:
o5jiM
RM N O ��oPoSP
64,;
i f- i
j✓��qw�� St�o�S �313r� .
N•r.s.