PW-12-20-2873Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Parcel Number
163 NW 101ST ST, Miami Shores, FL 33150 m 1131010230150
Contacts
THOMAS USAREK-WITEK Owner ACCESS GENERAL CONTRACTOR Contractor
MICHEAL HOFFMAN
4400 NW 109 TER, CORAL SPRINGS, FL 33065
__..... __._.._..__.._._ __..... ._.................._ .....__ ......_...__..... __.. _...---- .._...._----- .........._.__...._...---- ..._........... ............,........_........_....... ............... ...,.
I € '\' Ins ection Requests
Description: EVALUATE & REMOVE ASPHALT DRIVEWAY I Valuation: $ 1,200.00 3fI5 762 449
REPLACE WITH PAVERS IN DRIVEWAY & WALKWAY ON WEST
I ELEVATION & TERRACE (NORTH & BACKYARD) Y Total Sq Feet: 1,567.00 3..,
Fees
Amount
Education Surcharge
$0.40
Public Works Permit Fee
$100.00
Scanning Fee
$3.00
Technology Fee
$2.50
Tota I :
$105.90
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$105.90
Credit Card
12/18/2020 $105.90
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 above named contractor to do the work stated.
re:
/ Applicant / Contractor / Agent
Date
December 18, 2020 Page 2 of 2
"(Pliwin-19
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, FM,138 - -
PUBLIC WORKS PERMIT APPLICATION
Permit Type: Work in the Right -of -Way on Miami Shores Village or Miami -Dade Property
Permit#:DS— (V - 2 3
2d
Name of Applicant (if utility see below): C' 0�6ctic �-+�1 GI�'G►�
Owner off the following described property: . I J '
Legal Description: Lot Block �_ Subdivision Omal2. &4k Mdi
Folio #; :> i0 ( -04
Address: 1 3 1J13+, Si , M►Am, Jwgs FL 3315'6
UTILITY NAME:
Qualifier/Authorized Agent:
Address:
City:
Telephone:
State Certification or Registration #:
Email:
State:
CONTRACTOR NAME: /l((FX 6-n'e-d 6,qA/"�-
ZIP:
Certificate of Competency #
Qualifier/Authorized Agent: %/�dG,rh 14(i a'!n
Address: lV��lU
City: State: ZIP: ?-306-5--
Telephone: AC-' . b Email: 29!'.iS(:4n�
State Certification or Registration #: IL66 76 Certificate of Competency #:
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way:
Type of Work: ❑ Paving ❑ Utility ❑ Sidewalk ❑ Electric
❑ Landscape ❑ Antenna ❑ Other:
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
State:
Email:
ZIP:
❑ Irrigation
Value of Work for this Permit: $ 14)W � 00 Square/Lineal Footage of Work:
Permit Fee $ 100.00
Notary $
Bond $
***** Fees*****
Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
(if required) Total Fee Now Due $ 0�s; 16
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
Applicant or"Authorize ent
The foregoing instrument was acknowledged before
me this day of C)C f , 20 Li,, , by
6eZ16 v, a tl F (i I -e " k1d who
is personally known to me or who has produced
r L D l . as
identification.
NOTARY PUBLIC:
Sign: �L'wL
Print:31Sl�tcti.�
SEAL:
A]—
ELKIS MONCADA
Public. State of Florida
mission# GG 273249
MY Comm. expires Oct. 31. 2922
APPROVED BY:
Signature
Company/Utility Agent
The foregoing instrument was acknowledged before
me this 14J— day of yD(z'' , 20 ? t-- , by
h-!tc F cc--t) f'-,OC'r f-'1 CkX weo� who
is personally known to me or who has produced
,DrojLr 1� L'%Cc Y) Cc- as
identification.
NOTARY PUBLIC:
Sign:`Z —
Print:11C
i MncAc�
SEAL: _
t"•e.
SELENA ARANDA
,.
MY COMMISSION # GG 971705
'•EOF iL�•-=
EXPIRES:: March2�2,2024y
�� Wary r.y RJ& UM,.,t,,
*********************************
Public Works Director, or Designee
2017-04-1S
Miami Shores Village
Public Works Department
(305)79S-2210
Public works forms are available
from the building department,
10050 NE 2"d Ave., Miami Shores, FL 33138
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
OR BY, 32209 P9 1521 QPss)
RECORDED 11/24/2020 10:33932
HARVEY RLIVINr CLERK OF COURT
MIAMI--DARE COUNTY, FLORIDA
Whereas, (hereby referred to as the owner) V ot�Ki Gt'L L, I
Of the following described pr'operty: /Y V
Legal Description: Lot �IBlock Subdivision r� /��°<� Folio #;
Addr_-s,: I b3 N W 10154. S+ M iAM; 5h4re5 FL 33 I S a
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of way:
IN CONSIDERATION of the approval of this permit by the 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 Miami -Dade County to make repairs or maintain said items within the public
right of way including restoration of the 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 herby agree to indemnify and hold Miami Shores Village or Miami -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 14 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 obligation has been
cancelled by an affidavit filed in the Public Records of Miami -Dade County, Florida by the Village Manager of Miami Shores
Village (or his fully authorized representative).
Signature PueLil Z
Owner or Authorized Agent
State off
County of�-7
The foregoing instrument was acknowledged before me this t J day of Gf • 20 Z!i , by
4"".e lle 6, 1, °-e. re& who is personally known to me or who has produced
F L 0 L . as identification.
NOTARY PUBLIC:
Sign: Z 2
Print: _ ( �i'-r S 6 SEAL —�
��� AG' SELKIS MONCAD]Florida
_ n Notary Public, State of Commission# GG 27My comm, expires Oct. 3
2017-04-11