Press "RESET" to clear entire form:

Property Information

ADDRESS: BLOCK: LOT: APT.#

Owner(s) Information

NAME(S) ADDRESS
CITY: STATE: ZIP:
TELEPHONE 1: TELEPHONE 2:
CONTACT PERSON - NAME: TELEPHONE:

New Occupant(s) / Owner(s)

LIST NAMES OF ALL INTENDED OCCUPANTS OVER TWO 2 YEARS OF AGE:

NAME: NAME: NAME:
NAME: NAME: NAME:

APPLICANT'S STATEMENT

I AM AWARE I MUST PRESENT A FIRE CERTIFICATE TO THE HOUSING INSPECTOR BEFORE A CERTIFICATE OF OCCUPANCY CAN BE ISSUED. FAILURE TO MAKE AN APPLICATION FOR INSPECTION AND OBTAIN A CERTIFICATE OF OCCUPANCY FOR EACH NEW OCCUPANT OF A DWELLING UNIT IS PUNISHABLE BY A FINE NOT TO EXCEED $1,000 PER DAY.

_____________________________
SIGNATURE OF OWNER/AGENT

______________________
DATE OF APPLICATION

_____________________________________________________
SOCIAL SECURITY NUMBER or DRIVERS LICENSE NUMBER