Permit To Operate - California Department Of Housing And Community

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STATE OF CALIFORNIA
BUSINESS, TRANSPORTATION AND HOUSING AGENCY
DEPARTMENT OF HOUSING AND COMMUNITY DEVELOPMENT
DIVISION OF CODES AND STANDARDS
MOBILEHOME PARKS PROGRAM
APPLICATION FOR PERMIT TO OPERATE
(See Reverse Side for Instructions on Completing this Form)
DEPARTMENT USE ONLY
SECTION 1.
TYPE OF PERMIT REQUESTED
(Check appropriate boxes)
Collection No.
Date
Park ID No:
Original
Amended
PTO Fee $
State Fee
Transfer of Owner/Operator
Change of Name or Address
MH Lot Fee $
Change in Number of Lots (Addition of lots requires local approvals)
Lot Fee $
Amended PTO Fee $
Type of Park:
Mobilehome Park
Special Occupancy Park
Temporary Special Occupancy Park
Permit to Const.#
SECTION 2.
LOT INFORMATION
TOTAL
Number of Lots
Conditional Uses
Number of lots with an electrical system designed exclusively for:
Mobilehome Lots:
50 amperes
Special Occupancy Lots With Drains:
30 amperes
Special Occupancy Lots Without Drains:
Other
Total Lots:
SECTION 3. PARK INFORMATION. (All fields in this Section MUST be completed)
Park Name:
Telephone No: (
)
-
Location
(Street Address – DO NOT use P.O. Box)
City
State
County
Zip
Incorporated City
Unincorporated Area
Owner’s Name
Telephone No. (
)
-
Mailing Address
(Street or P.O. Box)
(City)
(State)
(Zip)
SECTION 4.
MANAGER INFORMATION (The Information in this section is optional)
Property Manager
Telephone Number ( ____ )
-
Mailing Address
,
(Street or P.O. Box)
(City)
(State)
(Zip)
SECTION 5.
OWNER CERTIFICATION
As owner of the park described above, I agree to all necessary inspections required to obtain a Permit to Operate.
I also agree that this
park shall be operated and maintained in accordance with the Health and Safety Code, Division 13, Part 2.1 and/or Part 2.3 the applicable
provisions of Chapters 2 and/or 2.2 of the California Code of Regulations.
I certify under penalty of perjury under the laws of the State of California, that the information provided in this application is true and correct.
Executed on
/
/
at
,
(Date)
(City)
(State)
Required Signature:
Printed Name:
DEPARTMENT USE ONLY
Signature of Inspector:
Date:
Distribution:
White - Park Yellow - Department
Pink - Inspector
Goldenrod - Area Office
HCD 500 Side 1 (Rev 7/04)

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