PW-19-1813Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
285 NE 103RD ST, Miami Shores, FL 33138
Contacts
Issue Date: 08/06/2019
Parcel Number
1121360130440
Permit NO.: PW-08-19-1813
Permit Type: Public,Works
Work Classification: Public Works
Permit Status: Approved
Expiration: 02/03/2020
KENNETH & DEENY LORBER
285 NE 103 ST, MIAMI SHORES, FL 33138
Owner HOME OWNER Contractor
HOME OWNER
Description: TREE REMOVAL Valuation: $ 0.00 Inspection Requests:
305-762-4949
Total Sq Feet: 0.00
Fees Amount
Payments
Date Paid Amt Paid
Public Works Permit Fee $500.00
Total Fees
$500.00
Credit Card
08/06/2019 $500.00
Total: $500.00
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 accepti this permit I assume responsibility for all work done by either myself, my agent, servants, or employes. I understand that separate
permits are requ ed fo ELECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
�'wnina. Futtr6rmore, I authorize the above named contractor to do the work stated.
Signature: Owner
/ Applicant / Contractor / Agent
Date
August 06, 2019 Page 2 of 2
Miami Shores Village
Public Works Department
(305)795-2210
Public works forms are available from the building department, 10050 NE 2"d Ave., Miami Shores,
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#. �N—u; .
Name of Applicant (if utility see below): )/t% % >E,q� L wA67a
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio#; //2/36o/3asl a
Address: .2*S_ $J6 /02 S,7-
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone: Email:
State Certification or Registration #:
CONTRACTOR NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
3/0 aid 9%a3�'
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: /E'6/Ao tc %�i9G f�1 /%c-�"� O/(/
Type of Work: ❑ Paving
❑
Utility ❑ Sidewalk ❑,eaklVctric ElIrrigation
❑ Landscape
❑
Antenna ❑ Other:;.;'`*�t
DESIGNER: Architect/Engineer:
Address:
City:
State:
Telephone:
Email: ' ,N�•
Registration #:
Value of Work for this Permit:
$
ll1'1low,
Square/Lineal Footage of Work:
***** Fees*****
Permit Fee $ 100.00
Notary $ Training/Education $ 0.20
Bond $ (if required)
Technology Fee $ 0.80 Scanning $
Total Fee Now Due $
'J— 00
tiC,
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 $2,500, the applicant must promise in good faith that a copy of the notice of commencement
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such posted notic the inspection will not be approved and a reinspection will be charged.
Signature Signature
Apo licant or Authorized Agent Company/Utility Agent
The foregoing instrument w s acknowledgeV before The foregoing instrument was acknowledged before
h me this ay of U 20 °I by me this day of 20, by
V1(T I1�f�t- .br 00 ' who who
-ts�ersonally knov+rn to me or who has produced is personally known to me or who has produced
ident$ication.
Print: U
SEAL:
APPROVED BY:
t'y�Y.PR/FT0''�/i���i
a
#00 20720
• Ac
•\`` :
identification.
Sign:
Print:
SEAL:
as
Public Works Director, or Designee
2017-04-15