Re-Occupancy Application REOCC-12-22-3156Miami 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 Permit No GOX -/2--22- 3ISI-,
APPLICATION
Contact Name: 0 ar-G e, �lrnAn er Phone#:L7'5") �;G2 -6 - 17
Buyer: q>c ci cSuce- Seller: C rf.5 -jqc, S[1,7c4t F
Realtor: Company Name:
Property Address: 10X . III, I F 103 .-ji-
City: Miami Shores State: Florida zip: 33l3 S-
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: 1 certify that all the foregoing information is accurate.
Applicant Namg:. [Qotr, cr, (S rZ ci rl2.—
Signature:
The foregoing instrument wa cknowledged before me this 1 C/
day of J7ece nj kR0 2Z by !�l nVm 2>"-kYt_�
who is personally known tome or who has produced
�J-tvZ L: L As identification and who did take an oath
NOTARY PUBLIC:
Sign:
VivienneYao
Print: -e_,n+\._ ..,s�.....,ec,,
Comm.:HH222410
=y., Expires: Jan.31,2026
My Commission Expires:
a Nola Public -State of Florida
'�i�n,° �aa• ry
Building Officials
Re-Occ $60.00
Notary $5.00
Total $ & S • 4'�)o
REV 4-10