PW-19-1401Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
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Issue Date: 07/02/2019
Location Address Parcel Number
61 NE 108TH ST, Miami Shores, FL 33161 1121360110460
Contacts
Permit NO.: PW-06-19-1401
Permit Type: Public Works
Work Classification: Public Works
Permit Status. Approved
Expiration: 12/30/2019
JOSEPH FULTON Owner SFL Contractor
61 N 108 ST, MIAMI SHORES, FL 33161 ALEXIS JAVIER BADA
Mobile: 3059057188 9835 SW 76 ST, MIAMI , FL 33173
Business: 7863568806
Inspection Description: REPLACE OVERHEAD POWER LINES TO Valuation: $ 1,000.00 Inspection Requests:
4949
UNDERGROUND.
TRENCH ASPHALT IN ALLEY AND RECOVER Total Sq Feet: 0.00
Fees
Amount
Education Surcharge
$0.20
Public Works Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$2.50
Total:
$105.70
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$105.70
Credit Card
07/02/2019 $105.70
Amount Due:
$0.00
In consideration of the issuance to me of this permit, I agree to perform the work covered hereunder in compliance with all ordinances and regulations
pertaining thereto and in strict conformity with the plans, drawings, statements or specifications submitted to the proper authorities of Miami Shores
Village. In accepting this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are required for ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating construction and zoning. Futhermore, I authorize the na d contractor to do the work stated.
Authorized Signature: Owner / Applicant / � tractor / Agent Date
July 02, 2019 Page 2 of 2
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�.o Miami Shores Village ; JUN 9 2� 19
Public Works Department `�(�
,(305)795-2210 BY
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores, FL 33138
. t
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property (�
Permit#: ` l.- U 6- 1- C) 6
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot I Lf Block Zl S Subdivision �. Wwr N9 5 M10 V" SVsrt Ss
Folio #; I I Z I -O! l - GgL-t -
Address: Ir, i NF_ rU9f4 5 mrar►�1 Sh���s �L_ 33i61`'
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
State:
ZIP:
Certificate of Competency #
CONTRACTOR NAME: - E /4 t mi kt- eS i'116-1-
Qualifier/Authorized Agent: 1¢/t14'!- 's
Address: / M2 _W ? tv -B=
City: ` ' State: PC ZIP: 7$IX �^
Telephone: 'A Email:
State Certification or Registration #.666I$77/ SrCertificate of Competency #: ,
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way: 'rte.uC_h ws� L- N \'k1\-C i G INc\ 'Q-C. coy<- z
Type of Work: ❑ Paving ❑ Utility • ❑ Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer: , •'
Address:'
City: State: ZIP', t
y
Telephone: '.E nbiI: '` r
Registration #:
Value of Work for this Permit: $ ��qua'ejLln-`e`a'i Footage of Work:
***** Fees*****
.y
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
Bond $ (if required) — r I Total Fee Now Due $ �dS - 7_0
C-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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of suchru-sted notice, the inspection will not be approved and a reinspection will be charged.
Signature
Xp-plicant or Authorized Agent
The for oing instrument was acknowledged before
me this o day of 20 Vq by
KnS�Vi( who
is personally known to me or who has produced
Imo- mil r-2 as
identification.
Sign:
Print:
SEAL:
APPROVED BY:
2017-04-15
Signature
&ml/any/Utility Agent
The foreg ng instrument as acknowledged before
methisda of I" 20 /S , by
who
is personally known to me or who has produced
hlmf-y as
identification.
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NQT�
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cr�veo * i
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: n— inA
O$€AL:
MY COMMISSION # GG136185
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I
Public Works Director, or Designee