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Rental License Application
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Steps
1.
Property Address Information
This section is complete
This section is incomplete
2.
Ownership Information
This section is complete
This section is incomplete
3.
Resident Agent
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This section is incomplete
4.
Emergency Contact
This section is complete
This section is incomplete
5.
Designated Agent
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This section is incomplete
6.
Lead Poisoning Prevention
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This section is incomplete
7.
Acknowledgement
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This section is incomplete
Property Address Information
License/Account ID#
Property Address being registered
*
Number of Units in the property
*
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Ownership Information
Owner Name
*
Owner Mailing Address
*
Primary Phone #
*
Secondary Phone #
Fax #
Email Address
*
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Resident Agent
Resident Agent Name
if applicant is a corporation or LLC)
Resident Agent Mailing Address
Primary Phone #
Secondary Phone #
Fax #
Email Address
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Emergency Contact
Emergency Contact Name
*
(if different from applicant) - indicate "Same" if not different
Primary Phone #
Secondary Phone #
Fax #
Email Address
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Designated Agent
Designated Agent Name
*
(if different from applicant) - indicate "Same" if not different
Designated Agent Mailing Address
Primary Phone #
Secondary Phone #
Fax #
Email Address
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Lead Poisoning Prevention
Structure Construction
*
Affected Property - Built prior to 1978
NOT an Affected Property - Built in or after 1978
Lead Certification Numbers
*
If not affected property, please type "Not affected"
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Acknowledgement
I hereby acknowledge my obligations and responsibilities pursuant to Chapter 95 and 197 of the City Code, a fair summary of which have been provided to the undersigned landlord or designated agent.
I hereby affirm under penalty of perjury that the information on this application, both for a rental facility license and with regard to lead poisoning prevention, is true to the best of my knowledge and belief. I also understand if there are any changes in property ownership, owner address or agent/contact information I will notify the Code Administration Office within 10 days of the change.
Print Name of Person Digitally Signing Application
*
Payment Information
*
Call Owner for Payment ($10 service processing fee)
Email Owner for Payment
Payment was submitted online with renewal
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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