PW-19-1414Location Address
Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Issue Date: 06/26/2019
Parcel Number
270 GRAND CONC, Miami Shores, FL 33138 1132060136210
Contacts
Permit No.: PW -06-19-1414
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 12/17/2019
Description: REPLACE SIDEWALK Valuation: $ 5,000.00
Inspection Requests:
1305-7652-4949
Total Sq Feet: 0.00
Fees
JODIE BLUM Owner
270 GRAND CONC, MIAMI SHORES, FL 33138
Home: 4154125469
CHAMPION CONCRETE Contractor
JAIME BASILIO
10280 NW 63 TER 105, DORALL33178
Business: 3052528055champion@yahoo.com
Other: 7864024802
1.00
Public Works Permit Fee 100.00
Description: REPLACE SIDEWALK Valuation: $ 5,000.00
Inspection Requests:
1305-7652-4949
Total Sq Feet: 0.00
Fees Amount
Education Surcharge 1.00
Public Works Permit Fee 100.00
Scanning Fee 9.00
Technology Fee 2.50
Total: 112.50
Building Department Copy
Payments Date Paid Amt Paid
Total Fees 112.50
Credit Card 06/26/2019 $112.50
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.
OWNER AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulatin4lconstruction anddo' uthermore, I authorize the above named contractor to do the work stated.
nature: Owner / Applicant / Contractor / Agent Date
Page 2 of 2
RECE,'JE®
d Miami Shores Village JUN 2 0 tins
Public Works Department
305)795-2210
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#: DS " oo — q
15 1 `I1 1
Name of Applicant (if utility see below):
ti1 -
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #; _ - 12-0
Address:
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency # Cf r. d '155049)01
CONTRACTOR NAME:AI
Qualifier/Authorized Agent:
Address:
City:
Telephone: D
State Certification or Registration #:
Requests permission to
way: 4
State:
Email:
ZIP:
Certificate of Competency #: CC05410om
II (describe work;atch separate page if necessary) in the adjoining right of
Type of Work: Paving Utility
Landscape Antenna
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State:
Email:
Sidewalk Electric
Other:
ZIP:
Irrigation
Value of Work for this Permit: $J Square/Lineal Footage of Work: l AA7
Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 1 1 —
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
I
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 hotice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is jqued. In the
absence of such posted notice, the inspection will not be approved and a reinspection Mil be charged.
g Q !A C— VV \ SignatureSinate "- -
pplicanti1J
Authorized Agent \
The f regoing i strumeasacknowledgmeth ( a of 20
C'
by
U1rn who
i e(so Ily know to me or w o has produced
411o!i0.i 3 I was
identification. VVNS 33
Waaia,/7
MIS •yhh 1 I
Z: EXPIRES
O • sept 15, W22.-
1 •Q
aaaa n t`
Con-1pany/Utility Agent
The fore oing instrument was acknowledged before
me this day of c - , 20 (J by
Ut(L. QPrSll,l who
i kno n me or who has produced
as
identification.
1!!1lllllll/l
Sign: S o
f • .
c ids G
Print: _:• ani;v,
SEAL:
A 0
i • :fie dlhm
APPROVED BY: C Public Works Director, or Designee
2017-04-15