Form 81-900 (1) - License Application Housing Inspection (Page 2 of 4) in pdf

Form 81-900 (1) - License Application Housing Inspection Page 2

14. OWNER, CORPORATION AND PARTNERSHIP (list three principals if corporation). Attach additional sheet with information if necessary.

NAME

TITLE

HOME ADDRESS (INCLUDE CITY, STATE, & ZIP CODE. P.O. BOX NOT ACCEPTABLE)

15. Owner/Operator Certification

I have received a copy of the Partners for Good Housing booklet and will forward it to the building manager.

I certify that the agent named below has been designated to act as my legal representative with regard to the property listed in

Section 1 of this application.

I further certify that the statements contained herein are true and correct to the best of my knowledge and belief. I understand

that if I knowingly make any false statements herein I am subject to the possible revocation of any licenses issued as a result of

my false application, and such other penalities as may be prescribed by law.

Owner's / Operator's Signature ____________________________________________________ Date ____________________

16. Agent Certification

I certify that I am the legal agent of the owner(s) in relation to the property listed in Section 1 of this application and that I am

empowered to accept service of notices, orders, summonses, etc., in relation to the subject property.

Agent's Signature ______________________________________________________________

Date ____________________

17. Lead Paint Disclosure and Certification

I further certify that the requirements of Philadelphia Code Section 6-803 (Lead Paint Disclosure and Certification), requiring a

certification of lead safe or lead free conditions to new lessees, and written notifications to such lessees, where applicable, have

been complied with for each such lease.

Owner's / Operator's Signature ____________________________________________________ Date ____________________

FOR OFFICE USE ONLY

18. Zoning Prerequisite

Remarks:

REVIEWED BY

ZONING PERMIT NUMBER

APPROVED

DATE

AUDIT

REFUSED

81-900 (Reverse of 1) (Rev. 12/12)

Form 81-900 (1) - License Application Housing Inspection Page 2