PW-17-1666Miami Shores Village
"
10050 N.E. 2nd Avenue NW
Miami Shores, FL 33138-0000
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Phone: (305)795-2204
�ORiDA
(Permit
____...._....
Permit NO. PW-6-17-1666
Permit Type: Public Works
Work Classification: Public Works
Pennit Status: APPROVED
Issue Date: 6/29/2017 1 Expiration: 09/27/2017
Project Address Parcel Number Applicant
104 NW 102 Street 1131010220130
ALFREDO R PATINO
Miami Shores, FL 33138- Block: Lot:
Owner Information Address Phone Cell
ALFREDO R PATINO 104 NW 102 Street
MIAMI SHORES FL 33138-
104 NW 102 Street
MIAMI SHORES FL 33138-
Contractor(s) Phone Cell Phone
HOME OWNER
ing: 1
Fees Due
Amount
CCF
$0.00
DBPR Fee
$0.00
DCA Fee
$0.00
Education Surcharge
$0.20
Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$0.80
Total:
$104.00
Valuation: $ 100.00
Total Sq Feet: 150
Pay Date Pay Type Amt Paid Amt Due
Invoice # PW-6-17-64408
06/29/2017 Credit Card $ 104.00 $ 0.00
Avallaoie Inspections:
Inspection Type:
Excavation
Review Public Works
Review Public Works
Final Public Works
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 p rmit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate permits are
required for EL TRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFF IT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating
constructio ing. Futhermore, I authorize the above -named contractor to do the work stated.
June 29. 2017
A th i Signature: Owner / Applicant / Contractor / Agent
Buildi artment Copy
June 29. 2017
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores, FL 33138
JUN 2 7 2017
1 1 .
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
D
Permit#:,�5(
Name of Applicant (if utility see below): A�F pz� 36S (M
Owner off the following described property:
Legal Description: Lot C— Block ''Z, Subdivision C-i�LDCQ�SC
Folio#; 11 --3( 61'DZ2-b13o
Address: l o y U V— 102., a S I -A C'"u2 s
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
Citv:
Telephone:
State Certification or Registration #:
Email:
CONTRACTOR NAME: �vv-Q-•�
Qualifier/Authorized Agent:
Address:
State:
ZIP:
Certificate of Competency #
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: 1J N Q 1n A.
Type of Work: M Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
Citv:
Telephone:
Registration #:
Value of Work for this Permit: $
State:
Email:
ZIP:
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 $ 1 C9
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 Signature
p t or Authorized Agent Company/Utility Agent
The foregoing instrument was acknowledged before The foregoing instrument was acknowledged before
me this 2'a day of20 (::) , by me this day of 20 by
-1'F��71:7l Ln who who
is personally known to me or who has produced is personally known to me or who has produced
as as
identification. identification.
NOTARY PUB C:
Sign:
r
Print: Cam%_ 11�0VJ�
SEAL:
y =ogg Notary Public State of Florida
} y Co Alvarez
m
My Commission FF 156750
} OF Rod Expires 09/031201 B
NOTARY PUBLIC:
Sign:
Print:
SEAL:
APPROVED BY: , Public Works Director, or Designee
2017-04-15