PW-19-1330Miami Shores Village
10050 NE 2 Ave
Miami Shores Fl. 33138
305-795-2204
Location Address
1421 NE 109IRD ST, Miami Shores, FL 33138
Contacts
WI --W
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Issue Date: 06/13/2019
Parcel Number
1132050310150
Permit NO.: PW-06-19-1330
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 12/10/2019
VILMA QUIZ TANA
1421 NE 103 ST, MIAMI SHORES, FL 33138
Owner CHAMPION CONCRETE Contractor
JAIME BASILIO
Other: 3055273904
10280 NW 63 TER 105, DORAL, FL 33178
1
Business: 3052528055 jaimechampion@yahoo.com
Other:7864024802
Inspection Requests:
Description: DRIVEWAY PAVERS Valuation: $ 6,200.00 305-762-4949
Total Scl Feet: 890.00
I
Fees
Amount
Education Surcharge
$1.40
Public Works Permit Fee
$100.00
Scanning Fee
$9.00
Technology Fee
$2.50
Total:
$112.90
Payments
Date Paid Amt Paid
Total Fees
$112.90
Check# 188
06/13/2019 $112.90
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. Ina pting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are req Ared for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing infor tion is accurate and that all work will be done in compliance with all applicable laws
regulating consFruction and zoning. Futhermore, I authorize t above named contractor to do the work stated.
I 'tN' / -,--
Authorized Signature: Owner / Applicant / Contractor / Agent
Date
June 13, 2019 1 Page 2 of 2
r!
LIE CEIVED
Miami Shores Village
Public Works Department JUN 111019
(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#V.20
S"o� -' J?
0 -1-q- 1330
Name of Applicant (if utility see below): _ V j (K - QU Ili')AAA
Owner off the following described property:
Legal Description: Lot V Block G Subdivision h tanfJSkOAyS /thy p #J/,&Sr
Folio #; �/` 3;Z06- 0 /- U/SO
Address: I Le U L467 103 yT H).,9" 5ho,473 3_FZ&
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency #
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address: eO
City: O State: d�'
IP: 3317 i '
Telephone: ,3U5 757,r i 5s Email: %+1►H'eGilbl��l U►t� � yy CM
State Certification or Registration #: Certificate of Competency #:a 6F6_5
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
1IGNER: Architect/Engineer:
Address:
City:
Tellephone:
Registration #:
Value of Work for this Permit: $
Permit Fee $ 100.00
Notary $
Bond $
State: }. ZIP: - +
Email:
Square/Lineal Footage of Work:
***** Fees*****
Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
(if required) Total Fee Now Due $ 1 ( Z • �j 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 notice of commencement must be poste at the job
site for the first inspection which occurs seven (7) days after the public works permit is isle
. In the
' I
absence of such posted notice, the inspection will not be approved and a reinspection wcharged.
J,, �— —
Signature �l4
Applicant or Authorized Agent
The foregoi instrument was acknowledge efore
�DV
e this n day of 20 by
&A— "A,7A to A who
is personally known to me or whij6)has produced
W
identification-.
NOT
rS►�:!
Sign:
"� •�_
•.7I�O.F
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Print
SEAL:
IM
Signature
Comoany/Utility Atent
The foregoing instrument was acknowledged before
me this Lk day of ZYLX1� , 201'�, by
who
is me or who hasp uced
N+2 3ATI C.i J as
identification.
N OTi
Sign:
Print:
SEAL:
* ***** * *****1****
**********************
1
APPROVED BY:
1�
l
Public Works Director, or Designee
2017-04-15
COVENANT OF
C. F N 21-319R 1357926
OR BK 31.476 F'9 3 j32 (1.F'9s )
+1'6,'.VEY RUVIN CLERK OF (:OURT
STATE OF LO 'IDA, COUNTY OF E1Tdil ��o cosy y
ERE '. CER 1FY that this is a tr py of the a�� CLE^ o0
G
origin . a i ti `s :ce on a
_ ,AD 20 " N
3 o�
'iTNESS my ha and Official v, n coon ms� Q
HA RV Clerk of it a d Cou Courts
D.C. '6AOFcouK�y�
s6F WA E TRINGER RiTYMA
Whereas, (owner) V U !'l'FY "AJ 0
hereinafter referred to as the owner of the following d ribed
property (address): ILl21 ME lt13 >T-
Legal Description: Lot Block Subdivision
Folio # / %— 3206 -- D 3/ r
Requests permission to install (describe work): r917'
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795.2204 /
Fax: (305) 756.8972
TRUCTION WITHIN RIGHT
Within the public right of way of (address)
IN CONSIDERATION of the approval of this permit by4he 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 authoyz§td represer)Cative).
Signature,
Owner or Agent
State of Florida
County of Miami Dade
The foregoing instrument was acknowledged before me this day ofJVIV1z , 20,, by
wk is personally known to me or ho has produced
as
NOTARY PUBLIC:
Sign:
Print:/�,�►�
JAIME ARMANDO BASILIO
MY COMMISSION # GG 227924
EXPIRES: June 12, 2022
SEAL: