REOCC-06-23-1421Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
RE -OCCUPANCY Permit No. 1` tam �` Z3-1y zt
APPLICATION �Y � 3S _ S _ - 1�3 �
0a"Ia11 RIH- qo(4 "`1Z03
Contact Name:
Phone#:
(11Ll-10(0-gz08
Buyer: k_�} laa � quii�Seller: tip( VjnaL yV _6t ,
Realtor: Company Name: N1-1
Property Address: 0 � 4 A
City:
Miami Shores
State: Florida Zip: 3�13
I hereby certify that I understand that the zoning for this property is for single-family residential use and that it is
unlawful for more than one family to reside therein. I also understand that any Certificate of Re -Occupancy that
may be issued by Miami Shores Village certifies only that the referenced property is being used for single family
purposes and that such certificate does not constitute any representation, warranty or certification as to the
condition of the dwelling or other structures on the property.
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate.
Applicant 1
Signature:
The foregoing instrument was acknowledged before me this
day of _ " 20i , by V IoL PU
who is personally known to me or who has produced 2i W? t,�S
Ucf L&L_— As identification and who did take an oath
NOTARY P LIC:
Sign:
Print _ V
My Commission Expires: Y/Z I f .Zany
Building Officials Approval:
p' NWaFY Putrlic Stale of Florida
P:a,2lin 32ri Zagury
My Comm saiprr GG 943219
ne Expires G41211242q
Re-Occ $60.00
Notary $5.00
Total
REV 4-10