PW-19-747Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
4
TIRfu 6L
Issue Date: 05/02/2019
Parcel Number
102 NE 107TH ST, Miami Shores, FL 33161 1121360070240
Contacts
Permit NO.: PW-04-19-747
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 10/29/2019
1AMES MILLS Owner
LELACK CONSTRUCTION Contractor
MICHAEL LELACK
11515 ne 6th ave, biscayne park, FL 33161
Business: 9542637120
Description: CONCRETE SWALE Valuation: $ 3,500.00 T
ion Reuests:
2-4949
Total Scl Feet: 900.00
Fees
Amount
Education Surcharge
$0.80
Public Works Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$106.30
Payments
Date Paid Amt Paid
Total Fees
$106.30
Check# 5235
05/02/2019 $106.30
Amount Due:
$0.00
Building Department Copy
In consideration of t issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto an in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In acce ing t is permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are requfed fo ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AF IDAVIT: 1 certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating co on an zbning. Futhermore, I authorize the above named contractor to do the work stated.
Authorized Signature: Owner / Applicant / Contractor / Agent
Date
May 02, 2019 Page 2 of 2
f+ 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
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#: ' �D2- (1 - 3Cs
- 6
Name of Applicant (if utility see below):.�S .T _ r'i'); LLS
Owner off the following described property:
Legal Description: Lot 8 Block aofj SubdivisionDc�; •rqs rr-1-a Si,7cxzc5 GK"r. . 3
Folio #; i i a 1 3c4 -- ao'4 pot 4 0
Address: Io2- ►nE• 10-4 5ixec-r . rr'n;ann; Solrr -s
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone: Email:
State Certification or Registration #:
State:
CONTRACTOR NAME: LE1-i�cK CanSiizc�t;Or�
Qualifier/Authorized Agent: I=toe--r-
Address: 05'+J4 n . 5rn1,4'G 12.c1 '74 . -V ado
ZIP:
Certificate of Competency #
City: ccx=crx 'r State: r-i. ZIP: 33cg3
Telephone: `SA (.,&43 4 S-43 Email: I r C), <& IC i^Ck - - CX -n
State Certification or Registration #: CGc r GiA4 oA+4 Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: C�xiC�n f c S �.9�1.E i 54k>Qe� neSl�
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna [y Other:
DESIGNER: Architect/Engineer:
Address:
City: State
Telephone: bnail: _
Registration #: _ ..
Value of Workforthis Permit:�'$r 3•m
CQ�G.rC.;� SwG 1�
ZIP:
Square/Lineal,Footage"of Work: 54 Ci
.`+^�•'`✓••, �.�„�.rti/�✓ ..y .i`..ltv�..-Mr �. #k k k k Fees 'k k#k# - + �1 .\.•,.r. .„. 1,
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ _lam
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 a recorded notice of commencement must be posted at the job
site for the first inspection wXe
curs seven (7) days after the public works permit is issued. In the
absence of such posted notic,nspection will not be approved and a reinspection will be charged.
Signature
The foregoing' rur
me this ay of
Authorized Agent
/as acknowledged before
20 (1 by
X— -t r t t-5 who
is perso y known to me or who has produced
ojeiUr--t - as
identification.
NOTARY PUB
Si
SEAL:
Notary Public lisle of Florida
Louis Gabriel Machado
My Commission 00 279150
11
aid Expires 11/26/2022
Signature.o
pany/urnity
The forei g
me this ay of 10fP n f 20 M ,by
I�`'1 c cam, �e l leC•�e who
is,personally known to me or who has produced
C�"- tO as
identification.
NOTARY BLIC:
Sign:
J�K: _L
Print:
SEAL:
+�or
"Vi, Notary Public State of Fionda
Louie Gabriel Machado
g My Commission 00 2791 so
pia Expime 11/20/2022
AA
APPROVED
BY:
t�,
Public Works Director, or Designee
2017-04-15
OR BK ?1�21 P3 2138 t1P3s1
Miami Shores Village {:`'-�';r�r' �; -c
r
`r,r
Building DepartmentOR
!111L�E't '�14��.IVF t.: <h L Ir:f1!
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204 Tj7
rr
Fax: (305) 756.8972
COVENANT OF CONSTRUCTION WITHIN RIGHT�OFaW Y
Whereas, (owner) WS ;\ S '."-
hereinafter referred to 4 the owner of the following describes
property (address): I0�- ne I M S+ Ifl iom'- Sborc� 33 t 61
Legal Description: Lot 8- Block 20S Subdivision n►
Requests permission to install (describe work):
1VIiam: Shof'fV &, n?0.3
M
ku t+y% r�¢ 1 s, c v, eL
Within the public right of way (address) 102 O-1 G+ i- lum, S�o:a1
33 I b f
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 co incurred in the removal and disposal of the item(s).
4. The undersigned further agr t these conditions shall be deemed a covenant running
with the land and shall re ' full force and effect and be binding on the undersigned, their
heirs and assigns, until ime as this obligations has been canceled by an affidavit filed in
the Public Re s e County, Florida by the Village Manager of Miami Shores Village
(or his fully t epresentative).
L ,
Signature
er or Agent
State of Florid
County of Miami Dade n
he foregoin013
rument as acknowledged before me this day of I-`e-� , 20 , by
me S ^ ' t r ho is personally known to me or who has produced
V�V-Qy s side tifica ' n.
NOTARY ' UBLI
Sign: ., Y� YAWYPRIETO
SEAL: MY COMMISSION # FF 214031
Print: EXPIRES: March 25, 2019
`Rf h�e� Bonded Thru Notary Pubic Underwriters