297 NE 97 St (2)Date
(Rev. 10/02/03)
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RE- OCCUPANCY
APPLICATION
Miami Shores Village
Building Department
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795 -2204
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Fax: (305) 756 -8972
Permit No. 1 ,l� 22) 204-
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Contact Name Luis Be-11 Phone # 7 6. Z3 ‘
Buyer Seller / Realtor Company Name
Property Address 297 N g 6 ,7 St.
City Miami Shores State Fl Zip 3 3 / 3 c
I hereby certify that I understand that the zoning of the 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.
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate.
Applicant Name Lat.. A .
Signature s��
The foregoing i strume t was acknowledged before me this day of , 20
by (ii , who is personally known to me or who has
produced <-1-0
■I I I I r■ • %A
Y PUBLIC:
Sign:
Print:
My Co mission Expires:
Building Officials Approval:
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as identification and who did take an oath.
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Commission '1D2s
3 , ,,
Re -Occ. $60.00
Notary $5.00
CCF $0.60
Total �5•
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