PW-19-1237Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
78 NW 99TH ST, Miami Shores, FL 33150
[ontacts
Issue Date: 05/30/2019
Parcel Number
1131010330070
Permit'wo.: PW-€It 'i19-1237
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 11/26/2019
OSVALDO GOMEZ Owner CHAMPION CONCRETE Contractor
78 NW 99 ST, MIAMI SHORES, FL 33150 JAIME BASILIO
Home: 7862620901 OZZIE1633@COMCAST.NET 10280 NW 63 TER 105, DORAL, FL 33178
Business: 3052528055 jaimechampion@yahoo.com
Other:7864024802
Description: PAVED ENTRY FOR DRIVEWAY ON SWALE . Valuation: $ 2,300.00 Inspection Requests:
REPLACE SIDE WALK 15 FT 305-752-4949
Total Sq Feet: 1,200.00
Fees
Amount
Education Surcharge
$0.60
Notary Fee
$5.00
Public Works Permit Fee
$100.00
Scanning Fee
$9.00
Technology Fee
$2.50
Total:
$117.10
Payments
Date Paid Amt Paid
Total Fees
$117.10
Credit Card
05/30/2019 $117.10
Amount Due:
$0.00
Building Department Copy
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 thi pe it I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for LEC RICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFID I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating constr zoning. Futhermore, I authorize the above named contractor to do the work stated.
Authorized
/ Applicant / Contractor / Agent
Date
May 30, 2019 Page 2 of 2
RECEIVED
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2n1 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 �J
Permit#: VSJ( 1(�
Name of Applicant (if utility see below): aVA-LDD G,54,n& z
Owner off the following described property:
Legal Description: Lot 0, 6 Block / Zg Subdivision X!5, 5�m 6 68 10-S
Folio #;
Address: 26 A/A) 9q sTQWT, ";AMi SGlAef5, FL- ;3lSD
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME: _(,I
Qualifier/Authorized Agent:
Address: 102ZlrD PLU'
City: --k d'k-
Telephone:-:n6 ?f r'
State Certification -or Registi
ZIP: 5 .5 117?-
D e4x^
f
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: PAVED elvmk FOR h Aedkl tuA-r., ORl 5uidi-97. RFPAtE t 169-6V -L!< I SST
Type of Work: Paving ❑ Utility 0 Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
1 ;Registration #:
Value of,Work for this Permit:
State:
Email:
ZIP:
$ ?3O0. 00 Square/Lineal Footage of Work: /400 _Zf
***** Fees *****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) Total Fee Now Due $ ( 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 posteV at the job
site for the first,inspection which occurs seven (7) days after the public works permit is iss d. In the
absence of such posted notice inspection inspection will not be approved and a reinspection wil a charged.
Signature
ApplicanVof Author?ZeffAgent
The foregoing instrument was acknowledged efore
me this day of 20, by
oSVA&AD'!� (a 2 who
is personally known to me or who has produced
r_--C_0 f?—x Nau, as
identification.
Signature
Com any/Utility Agent
The foregoing instrument was acknowledge fore
e this v`Z day of 20 �, by
�! A -- who
VTis ersonally known to m�' e�'ggrrw�who has produced
GJ �2 ( y as
identification.
NOTARY PUBLIC:
�� "IIIISIS/ llgl/i N0TA
``,;�9��'�.
Sign:
hQ.. n�
SEAL:E1L:
SINDIA ALVARBZ
MY COMMISSION # GG 238273
EXPIRES: September e0 Hers
Bonded Thru Notary
********************************************
APPROVED BY: ��O Public Works Director, or Designee
2017-04-15
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204
Fax: (305) 756.8972
OR BK 31.458 Pq 1703 (i.Pss)
i_i'. eii9."07
E16i'%NE:Y RtIVIh1, CL.E.R.K OF ;COUI;:-j
P1Ir`;11:i:-[iAi}r C`OLMTY, f LiOR'.W!;
STATE F FLORIDA, COUNTY OF DADE
HEREE Y CERTIFY that this is !"y O/ m@
4raffal fled in this o ' on__ -,I -_deY of
A.D.
WITNE myhan an��A9��c'''� b%w
HARVE VIN, G�R� Cadre
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAf'-
Whereas, (owner) L�50AL- bo
hereinafter referred to as the owner of the following described
property (address): AJA) �% 5`7 2 EC-7-
Legal Description: Lot to Block 12ff Subdivision M 11h*I i ::� hv1-e-5 6E74 l� F
Folio# //3/p /D �30Dfi0
Requests permission to install (describe work): SN5 ;f1 cc �H viz TtiAU� r' i i+ye`
QIvWl0Vr-- �C i5TIA16, 6 o Mc A&--'r€ s i r11'05 r+ N D 4 5nVj44-i-T OA) scti�.� L r✓'. 7
1013
Within the public right of way of (address) S AILO 3 c-�2eEr-
titlk-mi S11.0/2a/ , PL 3315z)
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 uch time as this obligations has been canceled by an affidavit filed in
the Public Records o de County, Florida by the Village Manager of Miami Shores Village
(or his fully autho�e representative).
Signature
' /Owner op%gent
State of Florida
County of Miami Dade
he fo ego' g ir� strument was acknowledged before me this (I}" day of avr , 20 (� , by
VC1 C�Om-ey- who is personally known to me or who has produced
y "JaVA icons,( as identification.
NOTA Y U LIC:
Sign: lr� rPl YANADYPRIETO
Print: n r SEAL: _ '' MY COMMISSION # FF 214031
EXPIRES: March 25 2019
'• ��� Bonded Thru Notary Public Underwriters
�R;