Mobile Home Permit Application Form - City Of Bowling Green

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Filing Date: _____________
Mobile Home Permit Application
City of Bowling Green
Neighborhood and Community Services
Please Print Clearly in Ink or Type
707 E. Main Ave, PO Box 430
PERMIT FEE $25.00
Bowling Green, KY 42102-0430
Phone: 270-393-3676 & 270-393-3615
Permit #
MH2016-
Fax: 270-393-3223
APPLICANT INFORMATION
Applicant ___________________________________
Street Address _______________________________________
City _________________________________
State ______
Zip Code _____________
Email __________________________________
Phone _____________________
Mobile _____________________
Park Name _____________________________ Manager ___________________________________
Park Address __________________________________________ Park Permit __________ Expiration ____________
Federal ID or Social Security #____________________ Homeowner Occupied?
Yes
No
Is this a rental?
Yes
No
Registered Home Owner ________________________________________ Phone _________________________________
Street Address __________________________________City _________________________ State ______ Zip Code ________
Phone_________________________________ Fax ________________________________________
CONTRACTOR INFORMATION
Address _______________________________________
Contractor Business Name ___________________________________
City ______________________________
State ______
Zip Code _____________
Suite/Unit/Apt # __________
Email __________________________________
Phone _____________________
Mobile _____________________
PROJECT INFORMATION
Mobile Home Make: ________________ Year: ______ Lot # ___________
Home is:
Single Wide
Double Wide
New Installation OR
No Electric for 6 Months
Serial No: ______________________________________
B-Seal ______________
HUD # _________________
Home Dimensions:
Length ___________
Width ___________
Total Square Footage ___________
Are any of the following present?
If yes, then proper setbacks are required, if you plan to construct any of these items then a separate permit is required.
Deck
Yes
No
Covered Porch
Yes
No
Storage Building
Yes
No
Health Department Inspection
Approved
Denied
1) Initial Inspection: Inspector _______________________________Date: ___________________
Comments: _______________________________________________________________________________________
2) Re-Inspection:
Approved
Denied
Inspector ________________________________ Date: ___________________
Comments: _______________________________________________________________________________________
AFFIDAVIT OF MOBILE HOME PARK OWNER OR MANAGER
Pursuant to Subchapter 6-12 of the Bowling Green Code of Ordinances, the undersigned duly sworn deposes and says:
1.
I am the Owner or manager of the mobile home park making application for the mobile home Installation Permit attached to this
affidavit.
2. I am knowledgeable of the requirements of the Kentucky Mobile Home and Recreational Vehicle park Act of 1972, Kentucky
Revised Statues 219.310 to 219.410, and Kentucky Administrative Regulations 902 KAR Chapter 15 and placement of this
mobile home in the mobile home park I own or manage is in compliance with those requirements.
3. I acknowledge that I am not relying on any statements or representations of the City of Bowling Green, nor any of its
employees, representatives or agents that the placement of the mobile home complies with the above requirements. It will
be the Applicant’s responsibility to meet ALL conditions required for Plan Review Approval.
Signature ____________________________________________________________
Date ______________________________
COMMONWEALTH OF KENTUCKY)
COUNTY OF WARREN)
Subscribed and sworn to before me by _______________, as the mobile home park owner or manager, this ____day of _____________, 20____.
____________________________________________ My Commission Expires _______________________
Notary Public, Kentucky at Large
December 8, 2015
Doc#597900

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