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Rental License Application
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This form has been modified since it was saved. Please review all fields before submitting.
Steps
1.
Property Address Information
(current)
This section is complete
This section is incomplete
2.
Ownership Information
This section is complete
This section is incomplete
3.
Resident Agent
This section is complete
This section is incomplete
4.
Emergency Contact
This section is complete
This section is incomplete
5.
Designated Agent
This section is complete
This section is incomplete
6.
Lead Poisoning Prevention
This section is complete
This section is incomplete
7.
Acknowledgement
This section is complete
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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