REOCC-09-23-2184 99 NE 103 StA
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
RE -OCCUPANCY
APPLICATION
Contact Name: 'DO V., j H
Buyer:
Permit No. �o [;° - D 1- 23 -21
(I a ► -\ Phone#: %96-_J (�6Z' 53. 4—
U,61r_ n7TSeller: Lit/ 1Of 1 ��L rl +')C -' anCA (41 G d"'I 1
Realtor: llav (rt 1 Company Name:
Property Address: C1 9� _ �103 S L r e�
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.
C
Applicant Name: U
V � L.e ,,v,n
Signature: a
The Ioreg ig in t ment was ack ❑ led A
before me this
day of . 20�, by
s pers fly known to me or who has produced
As identification and id take an oath
NOTARY PUBLIC: _ _ _
Sign:
Print: .
My Commission
Building Officials
State of Florida
w My Comm. Expires Jun 27, 2025
Bonded throVjh pational Notary Assn.
Re-Occ $60.00
Notary $5.00
Total
REV 4-10