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Miami Shores Village 44
Public Works Department
(305)795-2210 �� � � (v
Public works forms are available from the building department, 10050 NE 2nd Ave., Miami Shores, FL 33
PUBLIC WORKS PERMIT APPLICATION 161,
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
1 �(
Permit#: Q�1 `-I - Z ZZ
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #;
Address:
UTILITY NAME: �� �C� c c S —/ A S
Qualifier/Authorized Agent: Q A
Address: S/o/ N'- ,,?/ ��e
City: F �/ i ,ct� � � 0-4 F State: 1::2 - ZIP:
Telephone: 1f,S3 DrSG G Email: W e /_�4'ee-9- YZ/+ @-- C-_.4J C_- c
State Certification or Registration M Certificate of Competency #
CONTRACTOR NAME: - GG c d
Qualifier/Authorized Agent: u Jr
Address: a/ NLJ Z 1 A-v�
City: -2 D 4-c < ZIP: a 9
Telephone: Email: b 2; 2 p -7�-e-a 2 _ C, i,&i
State Certification or Registration #: Certificate of Competency #: - 14 a 9--
Requests permission to install (describe w rk, attach separate page if
way: E.ycuJA-G rL - J — /'"7-4-e
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric
❑ Landscape ❑ Antenna rZ Other: `Z , S k
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
Value of Work for this Permit: $
Permit Fee $ 100.00
Notary $
Bond $
State:
Email:
ZIP:
) in the adjoining right of
in
❑ Irrigation
Square/Lineal Footage of Work:
***** Fees *****
Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
(if required) Total Fee Now Due $ r�q=n
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 noticjaih
endgment must be posted at the job
site for the first inspection which occurs seven (7) days ') c works permit.is issued. In the
absence of such posted notice, the Inspection will ed and a remspectlon will be charged.
�.
Signature Signature
Applicant or Authorized Agent Company/Util Agent
The foregoing instrument was acknowledged before The foregoin instrument was acknowledged before
me this day of 20 by me this ' day of 20= by
who who
is personally known to me or who has produced is perso ally known to me or who has produced
as as
identification. identific ion.
NOTARY PUBLIC: NOTAR PUBL C:
HUBERTNUNEZ
MY COMMISSION # GG 104234
=ems EXPIRES: September 11. 2021
Sign: Sig `-<;Fr`:'Bonded
' Undorwrllers
Print: Print: `��/e
SEAL: SEAL:
* *******************************************
APPROVED BY: Public Works Director, or Designee
2017-04-15