REOCC-05-23-1260Miami 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
APPLICATION
Contact Name: Michal Ettelson
Buyer: Lorne Leibel
Realtor: Chani Ettelson
Property Address: 1690 NE 104th St
City: Miami Shores
Permit No. OC`C - 65 - 23 -- l2&0
Phone#: 646-339-7666
Seller: HM 1690 LLC
Company Name: Compass
State: Florida Zip:33138
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 Name: ' r 4 kl I
Signature: s
Vn
The foregoing
instrument was acknowledged before me this 1-7
day of . 20 23 , by I� Cjr\o'L (
who is personally known to me or who has produced �-
�C` As identification and who did take an oath
NOTARY PUBLIC:
Sign:
Print:
My Commission Expires: t (3 (Z`�' `•,;?F•
Building Officials Approval:!
Vivienne Yao
Comm.:NN 222410
Expires: Jan. 31, 2026
Notary Public - State of Florida
Re-Occ $60.00
Notary $-5A9
Total $ Co o
REV 4-10