Rental Registration Application Form (Page 2 of 2) in pdf

Rental Registration Application Form Page 2

Rental Registration Application

Number of Dwelling Units:________________

(Separate application required for each unit)

Number of TENANTS occupying unit:_______________Number of rooms:_______Number of Bedrooms:_______

Dimensions of each room:_______________________________________________________________________

Total square footage of rental unit:____________________

This application must also include the name and address of the insurance company, if any, providing the fire and

other hazard and public liability insurance for the owner of the premises and a description of the type of insurance

provided, policy limits for each coverage, and the policy number and expiration date of such policy.

Exceptions to this form are § 129-3 A (1) an accessory apartment, as defined by Chapter 154, for which a special

use permit issued by the Zoning Board of Appeals is in effect shall not be required to comply with the provisions of

this chapter. As well as §129-5 F Notwithstanding the above, no rental occupancy permit shall be required for a

residential-care facility established under New York State guidelines only with respect to housing of persons

requiring such care and excluding any housing provided for employees of such facility or other individuals.

The Code Enforcement Officer and/or Fire Inspector is authorized to conduct inspections, upon consent of the

owner or occupant, of any rental dwelling unit and the premises in which same is located, to determine the condition

of the rental dwelling units and to safeguard the health, safety, morals and welfare of the public. It shall be a

condition of each rental occupancy permit, expressly stated therein, that the Code Enforcement Official and/or Fire

Inspector shall have the right to inspect each permitted rental dwelling unit during the term of the permit, in

accordance herewith, for the purpose of performing his duties, under this Chapter.

REQUIRED FEES for 3 Year Rental Registration – Non-refundable

(yearly payment not acceptable)

$75 per unit

(up to 4 units)

$______________________

$50 per unit

(each additional unit in excess of 4)

$______________________

TOTAL FEE PER STRUCTURE

$__________________

owner/operator

of above referenced premise,

(please print) ____________________________________________,

(circle one)

do hereby certify that the above statements are true, to the best of my knowledge.

Signature of Applicant________________________________________Date_____________________________

Rental Registration Application Form Page 2