Re-Occupancy Application REOCC-12-22-3203Miami Shores Village f5N h. F 4ED
Building Department DEC 2 2 ZO 2
v \ 10050 N.E.2nd Avenue, Miami Shores, Florida 33138
Tel: (305) 795.2204 Fax: (305) 756.8972 BY:
INSPECTION'S PHONE NUMBER: (305) 762.4949
RE -OCCUPANCY Permit No. gacc_ )Z 13�03
APPLICATION
Sp�co�A e 1, n tm Ut\ oc,-vco��
135 rn co C
Contact Name: lf, , " ` LkP//16e'0 Phoone#: 363b qo
Buyer: Z Seller: '.::1161\Q VI1 62 nn ee
Realtor: GLC OA 112.Lr/ Q M Company Name rhQj VCR
Property Address: ' 1 LO `t O 0'E I d s '//
City: __ Miami Shores State: Florida Zip: �3 (325
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
IM
r ' "OeZIIA
Signature: %—� —
The foregoing nstrument was acknowledged b fore me tblisk2z
day of 20 Z�, by JA
who is personally known to or wl o has produced
ry) ) As identification anclAo did take an oath
NOTARY PUBLIC:
Sign:
4Expire
Print:My Commissio
Building Officials Approva
REV 4-10
Notary Public • $fate of Florida
National Notary AGSM
Re-Occ $60.00
Notary
Total