PW-05-20-1052Miami Shores Village MAY 2 6 20zu
Public Works Department BI'c
(3051795-2210 —
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-q,j - O —2-D - i D52
Name of Applicant (if utility see below): VAZ&A if, "J 9/E
Owner off the following described property:
Legal Description: Lot / Cy Block�Subdivision S17cl/{S E3747e5
Folio #;
Address: /47(r i 1 N �/r'✓eS
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
State:
CONTRACTORNAME: 0J//o+
Qualifier/Authorized Agent: k7fp rn e b:4 /%n
Addres�s�: O(o (0 7 iV 63 e // 2a-c..�
City: /yi4M1 /PS State: T- C
Telephone:30S-S27 Email:xhToeS
State Certification or Registration M CCU C /S 25 GS ?fie
Requests permission to install (describe work, attach sepArat
way: /)f mo a / A r,!>,4, A C
y/-i ✓t Al y
Type of Work: ❑ Paving ❑ utility ❑ Sidewalk
ZIP:
Certificate of Competency #
ors GLL
I' ZIP:
tificate of Competency #:
page if necessary) in the adjjoining right of
v M /v G I7
❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
_ State:
Email:
ZIP:
Value of Work for this Permit: $ O 00 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 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 notice, the inspection will not be approved and a reinspection will be charged.
Signature
or
Theforegoing4nWur
me this 2'0
-F day of
dged before
20 �ZWC7 by
who
to me or who has produced
as
Signature / /�
Company/Utility Agent
The foregoing instruments ackn wledged before
me this _ day of 20 �ZO by
who
is sonally knowWdto me or who has produced
as
identification. identification.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign•. �`IRJt..c., 02vt� signl'.K�.�'
Print: AWA• I�o i1.s °— ie?/eq Print: 4 A A AeA R.r 9 Pe / P 2
SEAL: SEAL:
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APPROVED BY: emu' Public Works Director, or Designee
2017-04-15
f••
Miami shoves Vlfhage"
Publk works Department
Public works form are avallable
from the building department,
10050 NE 2"d Ave., Miami Shoresr FL 33136
CoVENAW OF CONMUMN WMW MGNTOF WAY
Whereas. (hey i eferr+ed to as the owner)
CFN: 20200225353 BOOK 31895 PAGE 4023
DATE.04/14/2020 09:10:17 AM
HARVEY RUVIN, CLERK OF COURT, MIA-DADE CTY
i
Of the following described roperty: NOW M I S�iel�
UPI laesanption: E at / Ellodc melon ma's1-&e9Fofto N;
AddrAl eF W C,74 At'* Q �as � �3�.i07
Requests p nnissim to install (dessfe work sttxh separate POP If neCessary) in the adjoining right of war.
IN ODNSIDERAllow of IM approvel of this permit by the village, the owner agrees as foilows:
L To rnakwtaire and repair, when necessafy, the above -mentioned Item(s) Insglled within the deftated right of way. If it
beoomes necessary for Miami Shores Village or Miami -Dade County to make repairs or ngintain said urns within the RUbk
right of wa y induct ft ra morstion of the street by reason of the owner's failure to do so, such eapensie shall be paid by the
Omer or shag constitute a lien against the above described property until paid.
2r The owner does herby agree to indemnify and hold MI&W Shores Village or Misnni-Dede County harerehess firorr} any and an
fide ky, vehicle a" rise by virtue of pwnthttfng the installatlon. of these items within the pubk right of way.
3. The Owner does bereft agree to re hove or relocate their bdiitles at their own expense, within 14 days' ri ndr a by the
vilkW to do w F&Wre to comply with this nonce wig result in the Village causing the Itene(s) to be rernwmd and a Ian
bex g placed on the property and/or sssessd against for A costs Wowed in the. rernmAd and of the
itiernts�
4. The ur-flokrcion s further agrees that these conditions shall be der, i e s ewAmant run+dg w th dw land and shall remain la
full force and effect and be bkx&g on the undersigned, their heirs and assigns until such time as this obligation has been
uncoiled by an affidawt filed in She 7c Re.�oards o iNianti-Dade County. Florld+'e by tht Yt{iaRe 1�naga+r Miami Shows
Yrl fte {or his �1► rtsthorirsd j.
. �neRrerr
Oe+rreer Authoriaad
State of Vlam
. County of `.A24aw- 9 � �a
athrrawed4 me this L day 2•„.,,,_ by
who CP"W:M
Y ire at who his produced
as idarehfiat3on.
NO tARV Pi *M*. _
prjnt: 40.4 A Af /d qw WAL,
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