REOCC-09-23-2375 374 NE 95 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
APPLICATION
4Contact Name:
d" ZL,,.Pe_&W
Permit No. Re dC�, - Cq, Z3 23 75
one#: _��� �l' - C// 7?
Buyer: �n (l�F� U#� �o�l I p �e ler: �c.y- -e/'
Realtor: N 14 Company Name:
Property Address:
City: Miami Shores State: Florida
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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
Signature:
The fore oing instrument was ackn wledged before me this 4w-
114
day of , 20 4, by rTZAAAA 2W -P—G204_
who is personally known to me or who has produced
As identification and who did take an oath
NOTARY PUBLIC
Sign:
Print:
My Commission Expires: t I;
Building Officials
W.119
FLJACQUELINE PORTAL
MY COMMISSION # HH 067894
EXPIRES: January 22, 2025
°P' ggrQed PublicUnderwdters
Re-Occ $60.00
Notary 1
Total $ &v.
REV 4-10