REOCC-05-23-1337RE -OCCUPANCY
APPLICATION
Contact Name: Jai KOCh
Miami 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
Permit No. f�G 00-C —Ds' B -13-3 7
Phone#: 305-984-696E
Buyer: Manuel Lugo/Sheila Troncoso Seller: Kristina Fielder
Realtor: Jai KOCh
Property Address:118 N W 102 ST.
Company Name: Coldwell Banker
City: Miami Shores State: Florida Zip: 33150
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 NWpe: Peangchai Maqner
Signature:
The foregoing instrument was acknowledged before me this 2y
day of M r� , 20by Pic rl �j- �C-tn
who is personally known to me or who has produced
As identification and who id take an oath
NOTARY PUBLIC:
Sign:
Print: 1 V tZWN
_
l (3� � 2.e�z� =x�• •'=
My Commission Expires:
Building Officials Approval: 66C leds
Vivienne Yao
Gomn► :HH 222410
Expires. jan. 31, 2026
Notary Public - State of Florida
Re-Occ $60.00
Notary $5.00
Total $ &- -- C'9
REV 4-10