REOCC-08-23-1933 1290 NE 103 STAccess M1 1% 3\�
�I
aa,&el Compa-veliz)
C3o5)g31-I-X1-j--
RE -OCCUPANCY
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
IZ-". CV- IIi7i �1' J--:)
Permit No. a-o CG -60-2,3- /q33
APPLICATION
Contact Name: F s e d Phone#: 11I �-,5�5-�',� Z
Buyer: r "5eller� L rE
Realtor: O e u tr e Company Name: //a
Property Address: _I Z g D A!E 1 Q,? 4
City: Miami Shores State: Florida zip:�331 3 �F
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: ."a,
Signature:
The foregoing kitRrrri—ent was acknowledged before me this
day of� 20, by
who is personally known to me or who has produced FL
11 Ll�- G,- • As identification and who did take an oath
NOTARY P I .
Sign: 1
SY Pic CHRISTOPHER P. KELLEY
Pr0Hfission # GG 950755
My Commission Expires:. Sl �4 Expires May 21, 2024
Op ff Banded Thru Budget Notary Services
Building Officials Approva : v
Re-Occ $60.00
Notary $5.00
Total
REV 4-10