PW-18-3349Miami Shores Village
RECEIVED
`O" 1 Public Works Department
NOV 01 1018
(305)795-2210 �
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33138 ( Q
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: .f� deW 1 3 — J ��
Name of Applicant (if utility see below): SEE BELOW
Owner off the following described property:
Legal Description: Lot Block r1l
Folio #; 11-3206-017-1590 oil,
Address: 577 NE 96TH STREET
UTILITY NAME: TECO-PEOPLES GA
Qualifier/Authorized Agent: JESUS VEGA
Address: 5101 NW21stAVE.
ision
City: FT. LAUDERDALE State: FL Zip: 33309
Telephone: 954-453-0811 Email: ARROCHE@TECOENERGY.COM
State Certification or Registration #: E1608 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: INSTALL 2" PLASTIC GAS MAIN BY DIRECTIONAL BORE IN REAR ALLEY AND 1-1/4" GAS SERVICE LINE.
Type of Work: ❑ Paving ❑■ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State:
Email:
ZIP:
Value of Work for this Permit: $ 1,50o Square/Lineal Footage of Work: 925 FT
*****Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 6 1 - �I V
-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
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/Ut' ' Agent
The foregoing instrument was acknowledged fore
me this _Z,J day of G c-C 20 / by
who
is ersonally known to or who has produced
as
identification.
NOTARY PU I HUBERTNUNEZ
MY COMMISSION # GG 104234
Sign: ES
%Z Bonded Thru Notary Public Underwriters
Print:
SEAL:
* **** ************************************
APPROVED BY: 2 , Public Works Director, or Designee
2017-04-15