REOC-10-1118.10/02/03)
RE-OCCTJPANCY
APPLICATION
Date l I IP
Signature
Contact N
Buyer -
Property Address
Applicant Name
Building Officials Approval:
Miami Shores Village
Building Department
ON 7 1 ?No
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.10051.
Miami Shores, Florida 33138
Tel: (305) 795 -2204
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Fax (305) 756 -8972
:Permit No. Fes! v C-- ( C ) -- ( l S
Loc ID -
j S Phone# 3eo2
Company Name VJ 0/
Seller Realtor
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City Miami Shores State Fl
OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate.
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Sign: 1.
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Print: Up�rwRV PIMA
My Commission Expires: DD165901 p .
Commission i : Q ,
Zip J l - (42 1
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 ofRe-
Occupancy that may be issued by Muni 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;
The foregoing instrument was acknowledged before me this ( day of 75L , 20 0
by F 1 Tk-a- 2 , who i personally known toe or who has
produced as identification and who did take an oath.
NOTARY PUBLIC:
Re -Occ. $60.00
Notary $5.00
CCF $0.60
Total
Inspection Number: INSP- 146434 Permit Number: REOC -6 -10 -1118
Scheduled Inspection Date: June 22, 2010
Inspector: Bruhn, Norman
Owner: FARNHAM, JON
Job Address: 41 NE 107 Street
Project: <NONE>
Contractor:
Building Department Comments
RE- OCCPANCY
Passed
Failed
Correction
Needed
Re- Inspection
Fee
June 21, 2010
Miami Shores, FL
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspector Comments
PLEASE CALL JIM PETERS
41 NE 107 ST
For Inspections please call: (305)762 -4949
Permit Type: Re- Occupancy
Inspection Type: Re Occupancy
Work Classification: Re- Occupancy
Phone Number
Parcel Number 1121360070360
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