Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
_______
_
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
Address: ______________________________________________
Apartment #’s ____________
Type: Single-family
( )
Multi-family
( ) number of units if multi-family ________
Rooming house ( ) number of sleeping rooms
________
____________________________________
______
__________________________
Owner or Operator Signature
Date