REOC-09-1980 Miami Shores Village
Building Department
.10050 NY-2nd Avenue
Miami Shores, Florida 33138
SV Tel: (305 795-2204
R&OCCUPANCY IJ! Fax: (305) 756
APPLICATION. NGV J 2009 .-
i Permit No �
B Y: ��! - . - Loc ID
Date 6 �25
Contact Name L 9 Phones - 19
Buyer Seller Company Name
Property Address � ;92 /Vu-)
City Miami Shores State Fl Zip
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 informatiodis accurate.
Applicant Name p A – r A-- cdz== L
Signature
The foregoing instrument was acknowledged before me this day of ✓.�zJ 20 /
by . who is per sonally known to me or who has
produced as identification and who did take an oath.
NOTARY PUBLIC:
ONAE AIM
* WcolwMISSwN9ao716W
Sign; . may-, s, oP EXPIRB:.anuary 18, 2012 Re -Occ. $60.00
Print: Notary $5.00
My Commission Expires: ," a CCF $0.60
/ Total
Building Officials Approval: _o —f.� e/•d q
Rev. 10/02/03)
REG C07 1. 1 39 MC#01 06 1626 CHECK $60.00