PW-19-2279.tea
Miami Shores Village
Public Works Department ' 2 7 2019
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shork3; fi 3313
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property rf
Permit#.Is`
:T>t'V-09-1 J - zZ7 1
Name of Applicant (if utility see below):
Owner off the following described property: I
Legal Description: Lot Block Subdivision
Folio#; J%-3205 - 0Z0, 03eY0
Address: %JCS Nli2-- S'I A4 14 ✓ni
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
State:
CONTRACTOR NAME: 4/7kAHVI) 60Yv&1'e>'-
Qualifier/Authorized Agent: ../.Ov-C .d 3"
Address: 10WO /
City: -9 OWL State:
Telephone: • V L526y Emai : /J>L
State Certification or Registration #: Cer
Certificate of Competency #
ZIP:
cate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: CCVV44'! ,
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
Citv:
Telephone:
Registration #:
State: ZIP:
Email:
Value of Work for this Permit- $ 2 2-0 - Squire/Linealfootage of Work:
***** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ 10 (b ( O
7 -
s —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 wif be charged.
Signature
Applicant or Authorized Agent
The foregoi instrumett--was acknqwledged before
me this day of 20 by
y ho
is personally known t me or who has produced
as
identification. a
NOTARY PUBLIC:
Sign:
Print:
SEAL: � !'•"• MMEARMAND08ASIU0
W COMMIWM # GG 2Y M
Signature
Con any/Utility Agent
The foregoing instrument was acknowledged before
me this E day of 4�VJ77t�Nl 8-3L;-20 (1 , by
;7A1 r�R M-MA1A16>0 -r.S'IU O who
is personally known to me or who has produced
T\--* R VF.L uPEL&E as
identification.
NOTARY PUB :
Sign:
Print:
SEAL:
L—=
A ALVAREZ
SION # GG 238273eptember 3, 2022Notary Public Underwriters
**********************************************
APPROVED BY: (n Public Works Director, or Designee
2017-04-15
Am
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138 STATE OF
Tel: (305) 795.2204 I HEREBY
original file
Fax: (305) 766.8972
C-FN 21D19RID462382
OR BK. 715379 Ps 996 t lPgs i
RE a)RDEG i)7/24,12019
t;HR°ItEY F'IJt}I;{s _LERK OF (_rll R. T
IIIANI— ADE C`OUN T Y f F LORIUH
LORIDA, COUNTY OF MIAMi-DADc �o couHT\
:RTIFY that this is a tru o y of the °o
/ G
In t os E tee on
4 20 day of
J N
WITNESS rnhand and official S al.
HaRvi<Y i?UVsr,, Cleric of . ,.,
.lie
COVENANT OF CONSTRUCTION WITHIN RIGHT OIBWA- —
Tr
Whereas, (owner) f b f' P%'� TAMSHIAAMOLD #201144
hereinafter referred to as the owner of the following described
property (address): Cl Z5�1_
Legal Description: Lot Block Subdivision
-FOFto-#-_
Requests permission to install (describe work): IAZ 61�U7'� X2
Within the public right of way of (address) / 2 Z_ >�T
I'-fA.6 .LP- 3311
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 costs incurred in the removal and disposal of the item(s).
4. The undersigned further agrees that these conditions shall be deemed a covenant running
with the land and shall remain in full force and effect and be binding on the undersigned, their
heirs and assigns, until such time as this obligations has been canceled by an affidavit filed in
the Public Records of Dade County, Florida by the Village Manager of Miami Shores Village
(or his fully authorized representative).
Signature
Owner or Agent
State of Florida ��'�°`f �A,C-C%�
County of Miami Dade
T fore oing ' tr t w s knowledged before me this�Q day of 4_141�,20 �, by
f �e 'Who is personally known to me or who has pro uced
i fication.
NOTARY PUBLI ,�,.��- LUCIAESTRELLA
Sign: =�'RT i$SION#GG121005
-EXPIRES: July 2021PriTi SEAL: