Please Print or Type
PROPERTY ADDRESS:
ASSESSORS PARCEL NUMBER:
NEAREST CROSS STREET:
NUMBER OF UNITS AT THIS ADDRESS:
OWNERS NAME
(OR CORPORATE OFFICE):
OWNERS ADDRESS:
CITY, STATE, ZIP
OWNERS PHONE (HOME/CELL):
PROPERTY MANAGER NAME:
(IF AVAILABLE)
COMPANY NAME:
ADDRESS:
CITY, STATE, ZIP
PHONE (HOME/CELL):
IS THIS PROPERTY USED AS A SINGLE
FAMILY RESIDENCE?
YES
NO
IF NO, WHAT IS THIS PROPERTY USED FOR?:
RENTAL HOUSING CERTIFICATE APPLICATION
C I TY OF H ESPER IA
BUILDING AND SAFETY DIVISION
FOR OFFICE USE ONLY
INSPECTION:___________________________________________________________________________
INSPECTION DATE:_________________________ INSPECTORS NAME: _________________________
RESULTS OF INSPECTION: ______________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
PROPERTY APPROVED DATE: ____________________
FEES:
_____________
CERTIFICATE APPROVED DATE: ___________________
CASH/CHECK: _____________
CERTIFICATE #: _________________________________
RECEIPT #: _____________
_____________________________
___________________
_____________
Signature
Print Name
Date