REOCC-12-23-3175 168 NE 91 Stb i—WA_.F
Miami Shores Village DEC 21 �_(O
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
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RE -OCCUPANCY Permit No.., e -
APPLICATION
Contac ame: Y1 � e— S S --x-L� C-` Phone#• 2 3 S
er\tics
Buyer: Seller: C �z� de'� C�u�-<_ �� ut�n iak��h�;z�,)-6-1
Realtor: S>u Company Name:
Property Address: 1(0"C �1 �_ T '3 '3 � 3
City: Miami Shores State: Florida Zip: '3
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: fIfq
Signature:
The foregoing instrumeht-Wos acknowledged before me this
day of 5 � 20 J3 , by b1f,4ci
who is personally known to me or who has produced . i- jJ
%; e epst As identification and who did take an oath
NOTARY_ PUBLIC:
Sign:
Print:
r
My Commission Expires: I ve4,
Building Officials Approval:
REV 4-10
�o r►& Notary Public State of Florida
Fredrica Deanna Wiggins
y . My Commission GG 929493
V � Expires 111D6r2o23
Re-Occ $60.00
Notary
Total $ 61. C`'