REOC-16-1300 MAY 132016 Miami Shores Village � I
y
,>> : Building Department
10050 N.E.2nd Avenue,Miami Shores,Florida 33138
Tel:(305)795.2204 Fax:(305)756.8972
INSPECTION'S PHONE NUMBER:(3055)7614949
RE-OCCUPANCY Permit NgZ_Z - J.�dd
APPLIC:A'TION
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Contact Naane: phone#:
)sayer: ` e 2l ' ccs o seller: re L onS
Realtor:�ti T_� 0 Company Name:
Property Address: 1071;157 LJF=
City: Miami Shores State: Florida Zip:
I hereby certify that i understand that 'ng for this property is for single-family residential use and that it is
unlawful for more than one family to res �`" I also understand that any Certificate of Re-Occupancy that
may be issued by Miami Shores Village.certife a referenced property is being used for single family
purposes and that such certificate does not constitute an epresentation,wat7arrty or certification as to the
condition of the dwelling or other structures on the property.
APPLICANT'S AFFIDAVIT: I certify that all the foregoing info tion is accurate.
r�'t t0�oe )
Applicant Nae:-- V 044 t
Signature: Ij
The foregoing instrument was acknowledged before me this/
day of ,by
who' rsonally known to a or who has produced
identifica ion and who did take an oath
NOTARY publiG of oda
Sig xo "" Joanna Mn F PnOSV53
MY CM.0j j12(2015
My Commission Expires:
Building Officials Approval:
Re-Occ$60.00
Notary$5.00
Total $ �d
REV¢-10