REOCC-09-24-2462Miami 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
Contact Name:
Permit No. PE0CC-6ry-Zq_ Zq .Z
ne#: ,SOS -.3 O I- I b f o
III �I"- nn v L, Q
Buyer: IvICv7D 4S r�n,�;ggqn a Seller: CA 571 A �2�rY
Realtor: TGLCq(Ae(,'ne %Lr):YoCYo Company Name: MG r if Q
Property Address: -f oj� I(91 IN6' t3✓d SJ-
City: Miami Shores State: Florida Zip: �? 3) 3 f
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
Signature:
The foregoing instrument was acknowledged before me this e- -1-1
day of t ,20 bby�t uCAlrti Mi1rAAi' to
who is personally known to me or who has produced (mot_
�Jixs �`c- As identification and who did take an oath
NOTARY PUBLIC:
Sign: v
Print: V I V t-e_nrt Ya-v oawlll... VivienneYao
`=_ HH222410
L
My Commission Expires: l 19 i Z'o 4, Comm.:
-_ �` _
ExpiresAan.31,2026
Notary Public - State of Florida
Building Officials Approval:
2S
(REV 4-10/071920231.r .`-, W�ancy Application
RE-Occ: $60.00
Notary: $5.00
Total: 6 5,OU
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