Rental License Application Form - City Of Warren
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1RENTAL LICENSE APPLICATION
CITY OF WARREN
ONE CITY SQ., WARREN, MICHIGAN 48093
ATTN: RENTAL INSPECTIONS DEPARTMENT (586) 574-4633
(AN APPLICATION IS REQUIRED FOR EACH RENTAL RESIDENTIAL DWELLING)
Rental
Permanent
Address: ______________________________________________
Parcel No. ________________________________
(PRINT OR TYPE)
Owner: _______________________________________________
Home Phone: ______________________________
NAME (PRINT OR TYPE)
LAST
FIRST
MIDDLE
Owner’s
Address: ______________________________________________
Cell Phone: ________________________________
STREET (PRINT OR TYPE) (DO NOT USE P.O. BOX)
______________________________________________
Work Phone: _______________________________
CITY, STATE, ZIP (PRINT OR TYPE)
Driver’s License Number__________________________________
Date of Birth: ______________________________
MONTH
DAY
YEAR
Responsible
Local Agent: ___________________________________________
Home Phone: ______________________________
NAME (PRINT OR TYPE)
LAST
FIRST
MIDDLE
Agent
Address: _______________________________________________
Work Phone: ______________________________
STREET (PRINT OR TYPE) (DO NOT USE P.O. BOX)
_______________________________________________
Cell Phone: ________________________________
CITY, STATE, ZIP (PRINT OR TYPE)
Driver’s License Number___________________________________
Date of Birth: ______________________________
MONTH
DAY
YEAR
DWELLING TYPE:
Fee: $125.00
Fee: $250.00
Fee: $55.00
Group Home – Must provide
Single-Family Dwelling
Two-Family Dwelling
current State of Michigan license
__________________________
Late Fee: $25.00
I HEREBY APPLY FOR A BIENNIAL RENTAL LICENSE UNDER ORDINANCE NO. 80-418 (WCO 9.186-9.192) AS AMENDED, AND
HEREBY CERTIFY THAT THE ABOVE INFORMATION AND ANSWERS ARE ALL CORRECT AND TRUE AND THAT I AM THE
LEGAL OWNER OR RESPONSIBLE LOCAL AGENT FOR THE PREMISES AT THE ABOVE LOCATION. THE UNDERSIGNED
AGREE TO RELEASE THE CITY OF WARREN, ITS AGENTS, SERVANTS AND EMPLOYEES FORM ANY AND ALL LIABILITY
RESULTING FROM THE REQUIRED INSPECTIONS AND OBSERVATIONS HEREUNDER.
X_____________________________________________
__________________________
OWNER/RESPONSIBLE AGENT SIGNATURE
DATE
FOR OFFICE USE ONLY
PAYMENT
_______________________________________________________
RECEIPT NO.
DATE
AMOUNT
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