PW-05-22-1302Miami Shores Village
10050 NE 2 Ave
Miami Shores FL 33138
305-795-2204
Location Address
Permit NO.: PW-05-22-1302
Permit Type: Public Works
Work Classification: Public Works
Permit Status: Approved
Issue Date:05/26/2022 Expiration: 11/28/2022
Parcel Number
145 NW 95TH ST, Miami Shores, FL 33150
1131010240310
Contacts
Helen Ruby
Owner
CHAMPION CONCRETE Contractor
145 NW 95 ST, Miami Shores, FL 331501752
JAIME BASILIO
10280 NW NW 63 terr 105, DORAL, FL 33178
Business: 3052528055 jaimechampion@yahoo.com
Mobile: 7864024802
Home: 3059784333
Other: 7864024802
-}. Inspection Requests:
Description: REPAIR SIDE WALK Valuation: $ 5,000.00
305-762 4949
Total Sq Feet: 0.00
Fees
Amount
Education Surcharge
$1.00
Public Works Permit Fee
$100.00
Technology Fee
$2.50
Total:
$103.50
Building Department Copy
Payments
Date Paid Amt Paid
Total Fees
$103.50
Credit Card
05/26/2022 $103.50
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 ECTRICAL, PLUMBING, MECHANICAL, WINDOWS, DOORS, ROOFING and SWIMMING POOL work.
OWNERS AFFIDAV I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws
regulating convructi and zoning FLherrn^re, I authorize the above named contractor to do the work stated.
76-)-Z _
Owner / Applicant / Contractor / Agent
May 26, 2022
Date
Page 2 of 2
i Miami Shores Village
Public Works Department cTY Z
(305)795-2210 Z
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#:—US'_��
Name of Applicant (if utility see below):
Owner off the following described property:
Legal Description: Lot Block Subdivision
Folio#; 5101, 9?,q— 193/0
Address: i q>( Nov /y/1W4 �tJ /G-. 33rro
UTILITY NAME
Qualifier/Authorized Agent
Address:
City: State: ZIP:
Telephone: Email:
State Certification or Registration #: Certificate of Competency#
CONTRACTOR NAME: M %d(J
Qualifier/Authorized Agent: S`
Address: , V 2,1'd AIW t2G'
City: State: ZIP: ?7
Telephone: 1)?.Z-- Email: * At, V,49tj,00
State Certification or Registration #: Certificate of Competency #: NCO o B mOd'lf
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of
way:
Type of Work: ❑ Paving ❑ utility Sidewalk ❑ Electric ❑ Irrigation
❑ Landscape ❑ Antenna ❑ Other
DESIGNER: Architect/Engineer:
Address:
City:
Telephone:
Registration #:
_ State:
Email:
ZIP:
Value of Work for this Permit: $svvd Square/Lineal Footage of Work: %V O Sl
Permit Fee $ 100.00
Notary $
Bond $
***** Fees *****
Training/Education $ 0.20 Technology Fee $ 0.80 Scanning $
(if required) Total Fee Now Due $
Bonding Company's Name (if applicable):
Bonding Company's Address:
City:
State:
rAIS
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
thisjurisdiction. 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 #1 be charged.
Signature
U�Applicant-or Authorized Agent(/
The foregoing instrument was acknowledged before
me this 1 day of eA 202 by
ffy/fiU `JAl"who
is personally known tom or ho as pr duced
as
identification.
Signature
C(Ympany/Utility Agent
The foregoing instrument was acknowledged before
me this z3 day of 20 -L, by
$'r,j—, - eSA 4 tom) who
is persdza ly to me or who has produced
as
identification.
NOTARY PUBLIC: NOTARY PUBLIC:
Sign: Sign:
Prin I i S Print: a
SEAi0. '•Ya SEAL:JNMEARMANCO BA51LI0 .... •' MY COMMISSION # GO 227024 "`'�.-, ` ' I '2?FS. March OG8 50477
'•, pp' EXPIRES: June 12,2022 �0�80'Prb 24
"'FPS!„°•' eoMnd P,wN !x. PWrdr• undeiwhrs e
�. era
APPROVED BY: Public Works Director, or Designee
2017-04-15
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, FL 33138
COVENANT OF CONSTRUCTION WITHIN RIGHT OF WAY
CFN 2022RO3cP4113
OR SK 33187 Ps 776 (1P9s)
RECORDED 05/16/2022 14:10:07
HARVEY RUVINr CLERK. OF COURT
MIAMI-DADE COUNTYr FLORIDA
Whereas, (hereby referred to as the owner)
Of the following described property: _�/ r7 Z'/ — ��/ v
Legal Description: Lot Block Subdivision Folio S;
Address: I "l /ti/� `�f7 1'1jl'1�A41.i / 0AA0 '9 " 7 %J 61
Requests permission to install (describe work, attach separate page if necessary) in the adjoining right of way:
(&NA/fI
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
�O,w/nner or Authorized Agent
State of !
County of J //'/ -( /nI�
The foregoing
//instrument was acknowledged before me this `�L day of /J/� . 20�`•'by
e/�(e / I��/ who is personally known to me or who has produced
1 4 -AL, g iDD _Y6-53,614de tification.
OTARY PUBLIC: /
Sign:
JAIMEIWMANW2
IO
Print: •H'1�Wr�/ SEA ice.,• •i;; WCOMMISSIONI<Gq GG 22797924
?7 EXPIRES: Juno 12,2022
JWEARMAr• :.. L }: to
r �= MYCOMMISS10h9GG27924 Docume
'I ..�dr EXPIRES:J0812.2022
B�de4 Tin ficbn Public MIAMI-i
Midmi41e9,
22 N.W.
2017-04-11
WITNESS
:d at the Clerk of the Courts,
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and of o, °aa a, 4Courts
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By.
MIAMI SHORES VILLAGE
PUBLIC WORKS REVIEW
APPROVEDD2,_DATE � 22