RC-17-1482 (2)Miami Shores Village
Public Works Department
305)795-2210 J9
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#: Q(% 1-:4 - 4 °
Q . u+lam~ 2S
Name of Applicant if utility see below : r5rb APP ( tY )
Owner off the following described property: 0 Q,y, \ OJr tAAU-t A S W- -63
Legal Description: Lot 13 Block Io Subdivision 1T
Folio #, 1\— 3910417 - y 1__ — 0` k q
Address: 1000-4 NE LA ME , I (i3.1 A, %nre,s Fi-, 33( SC
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certifiyation or Registration #:
Email:
State: ZIP:
Certificate of Competency #
CONTRACTOR NAME: Sri\10u( kc0. C_orK-C(J SPIV
Qualifier/Authorized Agent: 10 u- ' 0%
Address: la 5 iS PIU $
City: c+h State: eu
Telephone: 30 LJ0- 6J 5_} Email: G 1 bwt lac- Ida e
State Certification or Registration #: C -C 01 t U n 1 Certificate of Cod
Requests permission to
way: M11124-t4f,
ems, 37nC,-
ZIP: 351,251
petency #:
all (describe work, attach separate page if necessary) in the adjoining right of
Type of Work: Paving Utility
DESIGNER: Arc
Address:
City: i
Telephone: Lx
Registration #:
Landscape Antenna
Sidewalk Electric Irrigation
Other:
Value of Work for this Permit: $ q60- W Square/Lineal Footage of Work: I I 61 02 0,1, 4 ,
Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scannin $
Bond $ (if required) Total Fee Now Due $ 1
Bondi Compan 's Name (if ap
Bo ing Co ny's Add res
Y. 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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absencesuch posted notice, the inspection will not be approved and a reinspection will be charged.
AfvSignatuSignatu "4- y%
Applicant or Authorized Agent Comp ility Agent
The foregoing instrume t as acknowledged b fore The foregot g instrument s cknowledged_bef
me is day of 20, by me this day of 20 y
J fjN,ok e-11., who L Q=3m 1 x L o l who
is personally known to me or who has produced is personally known to me or who has produced
as as
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
q,;, CATHERINE A.DUFFINoar
W. p'.- Notary Public - State of Florida
Commission # GG 104296
oT My Comm. Expires May 14, 2021
BgrR* lhrpugWN@ligrwlolarN f 9 s
APPROVED BY:
2017-04-15
identification.
NOTARY PUBLIC:
Sign:
a z
Print: v
SEAL: o,
9q e o•
if[
f11111
it %%N`
Public Works Director, or Designee
Miami Shores Village
Public Works Department
305)795-2210
Public works forms are available
from the building department,
10050 NE 2nd Ave., Miami Shores, FL 33138
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
lliNl EElil VIII lilll Iliil il ll VIII IIII III
C -Fick 2019 ROID7173
OR BK?i314 P9 2714 (IF-3s)
IRGED 112"05/2ii_c 1::;12, [i
iAR. _ RUVIIa r C:i_ER'r,. _iF COURTI
hIrj!II-Gr;DE11COUNTY'.., FL1ORIM-i
Whereas, (hereby referred to as the owner)OA `y, 0 0 NJl/ 6 (Z—
Of the following described property: of ar-P Pt Kt AAk. sv oras ) j()
Legal Description: Lot I 9013 `I$ Block
SubdivisionS 4 j Folio #; I 1 -' Z01
Address: _1 Q 0O - / ME- Ll Ave_ M1 C1 nv/ —s/to/:es
Requests p mission to install (describe wo , attach separate page if necessa) in the adjoining right of way:
orl
IN CONSIDERATION of t4 approval of this permit by the village, the owner agrees as follows: ` P( L
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 Miami -Dade County to make repairs or maintain said items within the public
right of way including restoration of the 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 herby agree to indemnify and hold Miami Shores Village or Miami -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 14 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 obligation has been
cance led by an affidavit filed in the Public Records of Miami -Dade County, Florida by the Village Manager of Miami Shores
Villa jer " fully ari d epre ntative).
Signature
Owner or Authorized Agent 6;A
State of Fl Li^/ q G„
County of 14 1 Au,t i - I Ad ,
The foregoing instrument was acknowledged before me this 1dayof (! br(Ie, V , 20111 by
V
S -k v-) 0 y e who is personally known to me or who has produced
as identification.
NOTARY P BLIC:
Sign: C
Print: ( . A14-ke rt 1\C V -_t''( f Ef ltipp p'
CATHE7yh
UFFIN
Nottry Pube of Florida
9 CnrmmisC,104296
y (:arum, ay 14, i6Z1
JKMledcd Throal NnlaryAssn,
ap
2017-04-11
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