REOCC-02-23-316 17 NW 110 StMiami Shores Village
RE -OCCUPANCY
APPLICATION
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
f)5 ._ 12 Z 1 -32 I ),
Permit No. � Vt/ - 0 t — 2. 2-- t/ %
O-OZ-2-3-�►to
Contact Name: UiN M. �acdkn Phone#:703- 09-g519
Buyer:.,It(ii��f lt�'` GfiCt5 Seller: 01 M. '[�eyc.�'li��an
Realtor: � � a a_V')W%V- s Company Name: ��11iWr I'l Qmb Cul4oJ
Property Address: 117 N. A 11 .5t
City: Miami Shores State: Florida zip: 33116 g
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: b i N , k. b ey-�I0 h
Signature:
The fore
]oing inst ent was acknowledged before me this
day of lam/ T 2023 by
whq is erso/nally known to me or who has produced!_
/ As identification and who did take an oath
NOTAPyy PUBLIC: I
Sign: r 1
Print: IT
andNotary Public State of Florida
My Commission Expires: Ca L Williams
My Commission
Ill! HH 261776
EXp. 5/5/2026
Building Officials Approval: 1 Re-Occ $60.00
Notary $5.00
Total $
REV 4-10