Rental License Application - City Of Medicine Lake

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City of Medicine Lake
10609 South Shore Drive • Medicine Lake, Minnesota 55441 • (763) 542-9701 • (763) 746-0142 fax
City of Medicine Lake - Rental License Application
License Year: ___________
Rental Fee: $30.00 per unit
Owners Name: __________________________________________________________________
Owner’s Address; ________________________________________________________________
________________________________________________________________
Owner’s Phone: Home/Work ________________________ Cell: __________________________
Agent Name: ___________________________________________________________________
If the owner does not live in Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Sherburne, Washington, or Wright
Counties the Agent shall be the person designated by the dwelling owner to be legally responsible for compliance with
Medicine Lake ordinances.
Agent Address: __________________________________________________________________
Agent Phone: Work _____________________________ Cell: ____________________________
Primary Contact (one person only) __________________________________________________
All correspondence will be sent to this person unless City representative is notified in writing of change to primary
contact designee
Email address: __________________________________________________________________
Emergency Contact: _______________________________Phone: _________________________
Address(es) of rental property: _____________________________________________________
Description of unit (
Description of unit must include whether it is the primary or secondary unit on lot, whether
the entire unit is to be rented, and a detailed description of the unity (single, duplex, multi, etc.): ________________
_____________________________________________________________________________________________
As signatory, I certify the above information to be accurate and compete as of the date shown below. I further agree to
permit free access and entry to the structure or premises under my control for inspection pursuant to City Rental
Housing Ordinance 79. I understand that providing false information may result in denial of this rental license
application.
Signature of owner: _________________________________________ Date: _______________
Signature of owner’s agent: __________________________________ Date: _______________
One application per rental owner is required. Failure to complete information or submit all fees
will delay licensure.
Please send any questions to
rentals@ci.medicine-lake.mn.us
Check number:
Date:
Amt:

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