REOCC-06-23-1620 165 NE 109 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 NJBO� —DO 93— (�020
APPLICATION
1l°i�t d� q5q ,.23a - Rq) a
Contact Name: Jeff Koebel Phone#: 305-606-2252
Buyer: Olympus Flips LLC _ Seller: Jeremiah R Heffron & Melissa L Cruz
Realtor: Jeffrey J Koebel Company Name: Montgomery & Koebel, Inc.
Property Address.165 NE 109th ST -
City: Miami Shores State: Florida Zip: 33161
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 N
be
Signature
The foregoing ins •u en was •nowledgeVo-elbel
orc me this 27th
day of June 2i. by Jeffrey J
.43
who is personally known to me or who has produced drivers
license / As identification and who did take an oath
NOTAR BLIC:
Sign ,
Print: errrinia Marrero
My Commission Expires:
Building Officials Approval:
i etiry POW stato of flerw
Re-Occ $60.00
Notary+
Total $ 60.00
REV 4-10