145 NE 98 St (7)Rev. 10/02/03)
RE- OCCUPANCY
APPLICATION
Date q- .Da-os
Miami Shores Village
Building Department
Contact Name — Oa r (e.,14 e. �Q SSer Phone # & 0 5 - 7 Y-. ly 7
Buyer Seller Realtor Company Name J),A-F Pe,� l
Property Address / ` F S I?) `i? "-/-
City Miami Shores State Fl Zip 33 / 3. ?
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 ic-&- r Leyte_ Ala Ss c - f - r -
Signature l L) t ��l/���,a�re�
The foregoing instru ent was acknowledged before me this .4- day of c 206S
by Q _ `1 a.who is personally known to me or who has
produced • as identification and who did take an oath.
NOTARY PUBLIC:
Sig n:
Print: b Lo L _
My Commission Expires:
LOIS E. UNDLEY
'; : 14 COMMISSION # DD 361851
-'.:- . EXPIRES: December 15, 2008
• Bonded Thru Notary Public UndenMters
Building Officials Approval:
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795 -2204
Fax: (305) 756 -8972
Permit No. 'Q00.-S° ?R
LocID
Re -Occ. $60.00
otary $5.00
CCF $0.60
Total C,, O. 69 0
Dat
Type Insp'n
Permit No.
MIAMI SHORES VILLAGE
BUILDING DEPARTMENT
305- 795 - 2204
B Iding Inspection Request
Approved
Correction
Re -Insp' n Fee
Name
Address
Company
Phone #
Inspection Date
G