REOCC-02-24-394 78 NW 99 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. PC__CxL -- &Z
APPLICATION
Contact Name: 0svaldo Gomez Phone#: 786-262-0.901
Buyer: John C. & Carrie L. Copeland Seller: Osvaldo Gomez
Realtor: Diana .Perez Company Name: Florida Realty qI'Miami Corp
. . ........... . .
Property Address: 78 NW 99 Street
City: Miami Shores State: Florida Zip: 33150
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
Signature:
Osvaldo
The foregoing instrument was acknowWdged before6he this
day of 20 __, by
who is personally known to me or who has produced
As identification and who did take an oath
NOTARY PUBLIC:
Sign;
Print 'i fl)
My Commission Expires: r— cz_t—<z� r 3 --) , 2—s, ') ?_j,
Building Officials
FA
REV4-10
INDYTROLLINGER
WC0MMIS$I0N*HH28i484
EXPIRES, Oclober 27,2026
Notary $5.00
Total $60,00