REOCC-10-24-2703Miami 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
Permit No.12
Contact Name: ,LasmE C t t-Cak�1 Phone#:-w6 J3S —T+Z-
Buyer: j7/�i(ZI( kC eck C IoN`1490 sever: CF�ival_I&f oAg At'n)gp� TtNcWt
Realtor: TE t2(M E C 4C aV, 1 Company Name: (,na i p wu
Property Address: I � Z k-� E 1 t 1 }t S TIZE (
City: Miami Shores State: Florida Zip:
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: 1 certify that all the foregoing ihformation is accurate.
Applicant Name: A )I) E4 7j
Signature: vIf
The foregoing instrumentb was acknowledge fore me this F)"
dayofO 09eY ,20aJ,Lby AUDQSS (ZrlmcNjU 6wM7-
who is personally known to me or who has produced -by L gir 1_1CQme-
As identification and who did take an oath
NOTARY PUBLIC:
Sign: I-ioCy /'+
Print: 1 yn
My Commission Expires:
Building Officials Approval: /
2N
RE-Occ: $60.00
Notary: $5.00
Total:
Pa t .I_ .,