MSV Public Works Permit ApplicationMiami 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
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right-of-Way on Miami Shores Village or Miami-Dade Property
Permit#: ____________________
____________________
Name of Applicant (if utility see below): ____________________________________________________
Owner off the following described property:
Legal Description: Lot __________ Block __________ Subdivision _________________________
Folio #; ______________________________
Address: _____________________________________________________________________________
UTILITY NAME: ____________________________________________________________
Qualifier/Authorized Agent: ______________________________________________________________
Address: _____________________________________________________________________________
City: ___________________________________ State: ____________________ ZIP: ________________
Telephone: ____________________ Email: _____________________________________________
State Certification or Registration #: ____________________ Certificate of Competency # ____________
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: _________________________________________________________________________________
_____________________________________________________________________________________
Type of Work: Paving Utility Sidewalk Electric Irrigation
Landscape Antenna Other: ____________________________________
DESIGNER: Architect/Engineer: _______________________________________________________
Address: _________________________________________________________________________
City: ______________________________ State: _______________ ZIP: _______________
Telephone: ____________________ Email: _____________________________________________
Registration #: ____________________
Value of Work for this Permit: $________________ Square/Lineal Footage of Work: _____________
***** Fees *****
Permit Fee $ 100.00
Notary $ __________ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $ __________
Bond $ __________ (if required) Total Fee Now Due $ ____________________
2017-04-15
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:
Sign: _______________________________________
Print: _______________________________________
SEAL:
Signature ____________________________________
Company/Utility 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:
Sign: _______________________________________
Print: _______________________________________
SEAL:
**********************************************
APPROVED BY: ___________________________________, Public Works Director, or Designee