REOCC-10-24-2668Miami Shores Village
Building Department
s 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
Permit No.
Contact Name: `T-A,-h �
AZ►rn O, Phone#: CIS --IS — 09 Oq
Buyer: TatLxtarLrna,-& Seller: rNO-iim, Go1dEii✓+n
Realtor: R11 ,'y i u rya & arc, a Company Name:
Property Address: 2J84 NVQ Al- wok it
City: Miami Shores State: Florida zip: 3 3 � SO
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. In addition, I acknowledge the requirement
for a swimming pool barrier to be in place and in compliance with code requirements at the time the pool was
constructed, repair and or re -surface.
APPLICANT'S AFFIDAVIT: I certify that all the foregoing information is accurate.
Applicant Name: 1 V A� b nG
:V-f\oTL
Signature:
The foregoing instrument was acknowledged before me this
day of Y 20'LN by
who is personally known to me or who has produep.d T--L, 0 ,-(v4—*- s
LL&4,0 S Z As identification and who did take an oath
NOTARY PUBLIC:
Sign: I
AA RE-Occ: $60.00
Print: U)-" "Id v 2 2- WENDY RODRIGUEZ Notary: $5.00
F�Bonded
of Florida
la y� No�ry Public -StateMy Commission Expires: 5l Commission k HH 528989 28Total:
M Comm. Expires MaY Y Assn.
through National Notary
Building Officials Approval:
REV 4-10%071920231. ) fp !% 2Pk1*#-occupancy Application Page 1 of 1