Application for Housing Or Vacant Property License for July 1, 2011 Thru June 30, 2012
APPLICATION FOR HOUSING OR VACANT PROPERTY LICENSE FOR JULY 1, 2011 THRU JUNE 30, 2012
Required by Ordinance 55-10, effective May 16, 2011
FEE: LICENSE NUMBER:
ADDRESS:
APPLICANT: DATE ISSUED: ____________
ADDRESS:
CITY, STATE, ZIP: PHONE:
NATURE AND EXTENT OF APPLICANT'S INTEREST IN THE BUILDING: ____________
(Owner, Manager, Other)
OWNER OF BLDG:
ADDRESS:
CITY, STATE, ZIP: PHONE:
THIS APPLICATION IS FOR THE LICENSE TO OCCUPY NOT MORE THAN ** Dwelling Unit(s)**.
The applicant hereby certifies that (1) he or she is the applicant named above; (2) that he or she is authorized by the owner(s) to operate the building above described in compliance with the Lakewood Property Maintenance and Safety Code and with all laws, ordinances, rules, and regulations applicable to such building or its operation; and (3) that all information provided on the reverse side is true and accurate.
NOTE: You must fill out the reverse side of this form. Please provide copy of governmental issued PHOTO I.D. (i.e., driver’s license, State issued I.D.) for identification purposes only. PHOTO I.D. PROVIDED
______
Date Signature of Applicant Owner’s Fed.I.D. No. or Social Security No.
The City of Lakewood, Ohio now accepts credit card payments.
Method of Payment: Check Enclosed Visa MasterCard
(Make Check Payable to: City of Lakewood)
Card Number: ---
Card Expires: Month/Year -
Card Holder Signature: ______
Card Holder Name: ______
(Please Print)
Please see reverse side of application for further information required.
ADDITIONAL INFORMATION REQUIRED BY ORD. 55-10, EFFECTIVE MAY 16, 2011:
1. (check one) At the property, at least one unit no unit has been occupied in the past six months.
2. Identify an adult person in Ohio designated to receive notices from the city:
______
Print name Street address in Ohio (no P.O. boxes)
3. Identify the property manager (if any):
______
Print name Street address in Ohio (no P.O. boxes)
4. Identify the person responsible for snow removal, lawn care and refuse bins:
______
Print name Telephone number
5. In what year was the structure erected? ______
6. How many stories does the structure consist of? ______
7. What type of heating system services the structure? ______
8. What type of hot water heating system services the structure? ______
9. How many smoke detectors exist in each residential unit? ______
10. What types of smoke detectors are in the structure? ______
11. The applicant hereby certifies (you must check at least two of these boxes to receive a license):
In leasing, the applicant uses a written rental agreement as defined in Section 5321.01(D) of the Ohio Revised Code.
In leasing, the applicant uses a reputable tenant screening agency for criminal and eviction background checks.
Within the past two years, the applicant or agent of the applicant has attended a landlord-tenant informational seminar.
Presenter and location of seminar: ______
12. The applicant hereby certifies that the applicant has personally witnessed, within the past twelve months (you must check the first three of these boxes and one of the last two boxes to receive a license):
Smoke and carbon monoxide detectors are present and operational.
No visible electrical or other hazards are present, and no readily observable conditions exist that represent a threat to the health and safety of any occupants.
Railings are present on interior and exterior stairs as required by applicable code.
If at least one unit has been occupied within the past six months, the heating system is operational; there is hot and cold running water in the kitchen and each bathroom with no leaks below the sink; and all toilets flush.
If no unit has been occupied within the past six months, the plumbing has been winterized to prevent the freezing of pipes; and all utilities to the structure have been disconnected, including electric service, which has been disconnected at the pole.
13. If no unit has been occupied within the past six months, you must send in the following additional documentation with this form:
n A copy of the declarations page for at least one policy of liability insurance covering the property.
n The combination to a rapid-entry system authorized by the Chief of Fire containing keys necessary to aid the Division of Fire in obtaining access to the structure in emergencies. For more information on what’s necessary, call (216) 529-6656 or visit http://onelakewood.com/PublicSafety/Fire/Default.aspx.
Your license fee is increased to a fixed amount of $200 (no matter how many units are in your property) if no unit has been occupied within the past six months. Please pay that amount rather than what appears on the front side of this form.