REOCC-06-23-1516 75 NE 92 STMiami 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.
APPLICATION
Contact ame: �j L 1' U J� 1��� Phone#: gq7 -7o-2 - ,/o3
Buyer: �A �c�d+ 3 Lf�� O -el Seller: rem min
-&
Realtor: C ri4 ✓ ek Company Name: Acc 0-ced '
Property Address:
City: Miami Shores State: Florida
Zip:
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: Ac � /no 5 6�zlirll
Signature:
The foregoing instrument was acknowledged before me this / Ll
day of V�� 20ZJ 'V by 3 G(L N'� u5 i Lem
who is personally known to me or who has produced
As identification and who did take an oath
NOTARY PUBLIC:
Sign:_(
Print: V l U i ��'►� '1
My Commission E
Building Officials
a•"""'Y p"'��. Vivienne Yao
2F�.....
Comm.:HH 222410
Expires: Jan. 31, 2026
Notary Public - State of Florida
Iq��1f1151{��•
Re-Occ $60.00
Notary $5.00
Total $ % S . vc�
REV 4-10