PW-19-1235RECEIVED
Miami Shores Village
Public Works Department MAY
(305)795-2210 -
Public works forms are available from the building department, 10050 NE 2"d 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
Perm it#.Pw-os -
Name of Applicant (if utility see below): DSU�-LSD 7
Owner off the following described property: `A ,
Legal Description: Lot %D � // Block I ZA Subdivision "`'t �C fp i06 /n-3)
Folio#; //- Rio/ -033' DO40
Address: -7g NW 9_g STET l�-1'i�lrii� 50�5, r� �53 /5d
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
Citv:
Telephone:
State Certification or Registration #:
Email:
Email:
State:
State:
ZIP:
Certificate of Competency #
ZIP:
Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: REIMLA44- (,�) -r12t=E-7S
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State: ZIP:
Email:
Value of Work for this Permit: $ 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 $
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 co y of the recorded notice of commencement must be posted at the job
site for the first inspection w ch occurs seven (7) days after the public works permit is issued. In the
absence of such posted noti e, the inspection will not be approved and a reinspection will be charged.
Signature
�``/
App c
t or Auloprized
Agent
The foregoing inst ument
was acknowledged before
me this JJ day of
20j �_, by
(-=4
'k who
is perPally known to me or who has produced
as
identification.
����g
NOTARY PUBLIC:
��\\\\1H1111►1
��`\QQ��M\gS ! •• /s/✓����
Sign:
Print:
* #FFa�7—�:Z1
SEAL:
ion • eordee:°t�
Signature
Company/Utility Agent
The foregoing instrument was acknowledged before
me this day of 20 by
who
is personally known to me or who has produced
as
identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
******************************************
APPROVED BY: Public Works Director, or Designee
2017-04-15