PW-02-22-501 Canceled_ CANCELLED rc�ta�d
Miami Shores Village �r
°^ Public Works Department j� nn ($
(305)795-2210 I'I°I�,(Il lJ is
Public works forms are available from the building department, 10050 NE 2n° Ave., Miami Shores !IR, 2 4 Z022
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade
jV l
Name of Applicant (if utility see below): A r nq Lermo
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio #; i I — 213 — 009 _O0 -40
Address: _114 N 5 1# n Sf - tom) i 0 .Mi S h O tees VL 331 to 1
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
Citv:
Telephone:
State Certification or Registration #:
Ck"
Email:
State:
yG hoo . C.Orn
ZIP:
Certificate of Competency #
CONTRACTOR NAME: 1 "%L U- L v r iC LLIr
Qualifier/Authorized Agent: (Li4�I (�ernArd2i 0pclrSGtC�
Address: �i15� SW 2SY11 S+ I�1i a rn fL 331 3f
City: t-rltctm( State: Y"L ZIP:
Telephone: 4;10 -345IEmail: mOidej-jCiS4 Q
State Certification or Registration #: Certificate of Competency
Requests permission to install (describe work, attach
way: V,Pmn"e— rjner- w�
Type of Work: ❑ Paving ❑ Utility
❑ Landscape ❑ Antenna
DESIGNER: Architect/Engineer:
Address:
Citv:
Telephone:
Registration #:
_ State:
Email:
if necessary) in the adjoining right of
❑ Sidewalk ❑ Electric ❑ Irrigation
ther: 1 12fnOLA-C7O[J
ZIP:
Value of Work for this Permit: $ ), GO CX) 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 $ 47
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 $2,500, the applicant must promise in good faith that a copy of the notice of commencemer
and construction lien law brochure will be delivered to the person whose property is subject to the
attachment. Also, a certified copy of the recorded notice of commencement must be posted at the job
site for the first inspection which occurs seven (7) days after the public works permit is issued. In the
absence of such posted notice, the inspection will not be approved and a reinspection will be charged.
Signature
�t�u al�i9"- Signature
pplicaaty thorizedAgent ompany/Utility Agent
The foregoing instrument was acknowledged before The foregoink4nstrument was acknowledged b fore
methis Zayof V:fi6 2022 by methis-2--q dayoffPil[ 20by
�1'h"Z L�i2.1yJ>, wh�{al 5'EJ.-- �.'�NP�'DE$ •{�j.�Z1 GlYrr.3who
is pers�o !ally known tome or who has produced is personallyknown to me or who has produced
f%l_ 0.2�vYC. as n 1rp M ,a7� LI e� r�S as
identification. identification.
NOTARY PUBLIC:
Sign:
Print:
SEAL:
APPROVED BY:
2017-04-15
NOTARY PUBLIC:
Sign:
Print: <7tc.T.i�wA
SEAL
":��� ••... SINDIA ALVAREZ
"a MY COMMISSION # GG 238273
*****************s***********************«*** EXPIRES: September 3. 2022
.`;fosi�'..•' 8oryW 7Mu Notary PuNc Undenrdlera
Public Works Director, or Designee