REOCC-04-24-910Miami Shores Village
Building Department
10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel:(305)795.2204Fax: (305)756.8972
INSPECTION'S PHONE NUMBER: (305) 762.4949
RE —OCCUPANCY Permit No. R�� bq
APPLICATION
Contact
GtName:
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Buyer. 1J \�W '—fie\ °^�^� LLGSeller: 01\A<2-�1 �—ov M .e—
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Realtor: Company Name.
Property
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City: Miami Shores State: Florida zip: 33\�
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 foregoing instrument was acknowledged before me this
day of—f '201�by
who is personally known tome or wh a d�jked -Cl
Y.ye-n As identification and who did take an oath
Sign:,
Print:
My Commission Expires:
Building Officials
KRISTINE KEPPLE YAO
NtttatyPobhL - State of Florida
Commission # HH 452227
My Comm. Expires Oct S, 2027
.bthrauah National Notary Assn.
Re-Occ $60.00
Notary $5.00
Total
REV 4-10