Transcription of PUBLIC WORKS PERMIT APPLICATION - Miami-Dade
1 Process No. _____Trans No. _____Date: _____Clerk: _____Job Address _____Folio _____Driveway ApproachEALot _____ Block _____ PB _____ PG _____Driveway (interior)SqFtSidewalkLFCurb & GutterLFPaving (Parking Lot)SqFtPaving (Street)LFSeal CoatingSqFtDrainageLFElectricLFGasLFTele communicationLFWaterLFSewerLFTraffic SignEAOtherJob No. _____Bond No. _____oSubdivision oComm oWarehouse oMulti Family Res oSingle Family S AFFIDAVIT: I certify that all of the foregoing information is accurate. _____ _____Signature of Owner or Owner's Agent Signature of QualifierPRINT NAME _____PRINT NAME _____STATE OF FLORIDA COUNTY OF miami -DADESTATE OF FLORIDA COUNTY OF miami -DADES worn to and subscribed before me this _____Sworn to and subscribed before me this _____day of _____, 20_____day of _____, 20_____(SEAL) _____(SEAL) _____ Personally known Produced Identification Personally known Produced IdentificationType of Identification Produced _____Type of Identification Produced _____Address _____* An authorization letter on Company letter head from the qualifier will be required for any other person picking up the PERMIT /plans.
2 City _____, FL Zip_____Phone _____WARNING TO OWNER: The issuance of the PERMIT does not relieve the property owner from obtaining homeowner's assocation approval (if required) prior to beginning any work and in no way authorizes work that is in violation of any association rule or _____Email_____PROJECT INFORMATIONName _____CGC not registered with miami dade County Building Department must provide proof of insurance, workman's compensation insurance and status of is hereby made to obtain a PERMIT to do work and installation as indicated. I certify that all work will be performed to meet the standards of all laws regulating construction in this TO PICK UP PERMIT /PLANS *Name _____City _____, FL Zip_____Along _____ From _____ To _____Along _____ From _____ To _____OWNER INFORMATIONName _____Address _____City _____, FL Zip_____Phone _____Email_____CONTRACTOR INFORMATIONC ontractor No.
3 _____NAICS Code_____Contractor's Name _____Address _____LOCATION INFORMATION# of MH,HH, PolesTYPE OF WORKDIMENSIONSPUBLIC WORKS PERMIT APPLICATIONC onstruction PERMIT ApplicationMiami dade County (SPCC) 14FL111 NW First Street, miami , FL 33128 Phone (305) 375-2142 , Fax (305) 375-2178PA 08/21/2014
