RESIDENTIAL RENTAL PROPERTY
INSPECTION PERMIT
PLEASE CHECK: □ NEW □ RENEWAL
City of Pittsburg, CA
Building Division
65 Civic Avenue
Pittsburg, CA 94565-3814
Telephone: (925) 252-4910
Fax: (925) 252-4814
DATE:
FOR OFFICE USE ONLY
PERMIT NO.
A. GENERAL INFORMATION
1. Subject Property Address:
2. Housing Entity Type-Check One of the following
□ Single Family
□ Duplex
□ Triplex
□ Four-Plex
□ Multi-Unit Over 4 units
□ Other
3. Property Owner Name/Mailing Address:
4. Property Managers Information (if applicable):
Mgrs. Telephone No.:
Mgrs. Cell Phone No.:
Mgrs. Unit No. & Address:
5. Property Owner Contact Phone #’s:
6. Total No. of Units:
1. ( Four or more units requires a posted notice with Mgr
address, Unit & Phone # )
2. ( Sixteen or more units requires a full time resident
manager on the premises)
7. Assessors Parcel Number:
Residential Rental Program Fees
8. Local Emergency Contact Information
(if applicable):
1. 2nd Year Enrollment
(self-certified properties only)
2. 2nd Year Enrollment
(non-self-certified properties only)
3. Additional Units(s)
(For each unit over 4)
4. Citation Total (if applicable)
5. Total Amount Due (#1 through #4)
$32.50
$71.68
$8.00
$0.00
Total
$ _______
$ _______
$ _______
$ _______
$ _______
Signature of Owner:
Signature of Owner’s Representative:
Print Name of Owner or Representative:
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY,
THAT THE INFORMATION CONTAINED HEREIN, IS, TO
THE BEST OF MY KNOWLEDGE, A TRUE AND
COMPLETE STATEMENT.
Date:
Rental Housing Owner “Self Certification”
Well maintained properties with no existing violations of the
California Building Code, Uniform Housing Code, and
Uniform Code for Abatement of Dangerous Buildings or the
Pittsburg Municipal Code may qualify to participate in the
Residential Rental Property Inspection Self-Certification
Program for up to three years. To be eligi