PW-17-1040 (2)7ED)R
C"Miami Shores Village 2 &52017
Public Works Department v\—
�' (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#: Pw uT !? -/0 1-0
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #; ,-
Address: Q? -3 N Z oe
UTILITY NAME:lCO
Qualifier/Authorized Agent: ✓cs� ✓F4A
Address: / S1 9 9
City: N. to.~ % a % State: ZIP: M/ 46
Telephone:ysy- y.t3 oV4S* Email:- s4Ac4-62eizA C- TEeo eAle- 2gy• Gam
State Certification or Registration #: Certificate of Competency # -e- �CQB
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
Requests permission to install (describe
way:
Type of Work: ❑ Paving jwlrj
{ Utility
❑ Landscape ❑ Antenna
DESIGNER: Architect/Engineer:
Address:
City:
Telephone: _
Registration #:
ZIP:
- Certificate of Competency #:
attach separate page if necessary) in the adjoining right of
State:
Email:
❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Other: bares' •
ZIP:
Value of Work for this Permit: $ 1 07" " 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 $ 6�(- G V
J
V
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 af�er the public works permit is issued. In the
absence of such posted notice, the inspection will no# lj!p.�-ovecl 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
Signature U � -�
Company/Utility ent
The foregoing instrument was acknowledged before
me this 2 4 day of e5z-o--t , 20 /7 , by
✓�90 who
is personally known to me or who has produced
as as
identification. identificat' n.
NOTARY PUBLIC: NOTARY UB C:
Sign: Sig .
Print: Print:
SEAL: SEAL: YP�e ehi NUNEL
Notary Public Sate of Flo]An
My Comm. Expires Sep 11,
Commission # FF 043679JR. OQ:.
"' Bonded Through National Notary
**** *************************************
APPROVED BY: 1 Public Works Director, or Designee
2017-04-15