Maplewood Missouri

							                                                        CITY OF MAPLEWOOD
                                                        7601 Manchester Road
                                                      Maplewood, Missouri 63143

                                           APPLICATION FOR OCCUPANCY PERMIT

I hereby request permission to occupy

ADDRESS____________________________________________________________________ APARTMENT NO.____________

APPLICANT’S NAME_______________________________________________________________________________________

DATE OF BIRTH____________________                   DRIVER’S LICENSE NO. (or SOC. SEC.)___________________________________

PLACE OF EMPLOYMENT __________________________________________________________________________________

WORK ADDRESS___________________________________________________                      WORK PHONE _______________________

SPOUSE’S NAME (if occupying unit/house) ___________________________________________________________________

DATE OF BIRTH____________________                   DRIVER’S LICENSE NO. (or SOC. SEC.)___________________________________

PLACE OF EMPLOYMENT___________________________________________________________________________________

WORK ADDRESS_____________________________________________________                    WORK PHONE _______________________

CHILDREN’S FIRST & LAST NAME(S) (if occupying unit/house)                       DATE(S) OF BIRTH                    SEX
                                                                                                         (M,F)

_________________________________________________________________________________________________________


_________________________________________________________________________________________________________


_________________________________________________________________________________________________________


_________________________________________________________________________________________________________

OTHER PERSONS WHO WILL OCCUPY THE UNIT/HOUSE                      DATE(S) OF BIRTH    SOCIAL SECURITY NO.
RELATIONSHIP


_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

TOTAL NUMBER WHO WILL OCCUPY THE UNIT/HOUSE ______________                                 PHONE NO. ___________________

RENTING? ( ______ )             BUYING? ( ______ )

NAME OF OWNER OR AGENT _______________________________________________________________________________

ADDRESS _______________________________________________________________                    PHONE NO. ___________________


MAIL PERMIT TO: _________________________________________________________________________________________

I CERTIFY THAT I AM THE PROPOSED OCCUPANT, AND THAT THE ANSWERS WRITTEN HERE ARE TRUE AND ACCURATE
IN ALL RESPECTS TO THE BEST OF MY KNOWLEDGE.


SIGNATURE OF APPLICANT(S) _______________________________________________________DATE



The fee for a residential occupancy permit is $15.00, non-refundable. The fee must be paid at the
time of application.

THIS IS NOT THE OCCUPANCY PERMIT. THIS IS THE APPLICATION FORM. DO NOT MOVE IN
UNTIL A PERMIT IS ISSUED TO YOU.
G:\Public Works\Building Division\occpermt.app (Rev. 3, 6/06)