REOC-09-2010Miami Shores Village
Building Department
RE- OCCUPANCY
APPLICATION—
10050 N.E.2nd Avenue
Miami Shores, Florida 33138
Tel: (305) 795 -2204
Fax: (305) 756 -8972
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Date i �� / (6 BY:
Contact Name M Q K Mai Phone # nc' 5 i7 - 39 Err
Company Name / / /t"- ?((4,14
Loc ID
Buyer
Property Address 3� e- 6111
City Miami Shores
Seller Realtor
State Fl
Zip S41 t 3Y
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.
itA0.1.1
Applicant Name
Signature
The foregoing inst ment was acknowledged before me this 4- day of
b y� � j
a'aJ , who is personally known to me or who has
produced as identification and who did take an oath.
20
Sign:
Print:
My Commission Expires:
NOTARY PUBLIC:
Building Officials Approval:
(Rev. 10/02/03)
Re -Occ. $60.00 N
Notary $5.00
CCF $0.60
Total
Inspection Worksheet
Miami Shores Village
10050 N.E. 2nd Avenue Miami Shores, FL
Phone: (305)795 -2204 Fax: (305)756 -8972
Inspection Number: INSP - 130865
Scheduled Inspection Date: December 14, 2009
Inspector: Bruhn, Norman
Owner: LUCIO, GLORIA
Job Address: 436 NE 94 Street
Miami Shores, FL 33138-
Project: <NONE>
Contractor:
Permit Number: REOC -12 -09 -2010
Permit Type: Re- Occupancy
Inspection Type: Re Occupancy
Work Classification: Re- Occupancy
Phone Number
Parcel Number 1132060140340
Building Department Comments
Passed 01 JI.
Failed
Correction
Needed
Re- Inspection
Fee
No Additional Inspections can be scheduled until
re- inspection fee is paid.
Inspector Comments
PLEASE CALL BEFORE GO
TONY RODRIGUEZ 305.303.1440
December 11, 2009
For Inspections please call: (305)762 -4949
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