Submit to: Neighborhood Services 34 W. Jackson Street Riverwalk Center, Tower 3 Battle Creek, MI 49017 Phone: 269.966.3379
Address of Dwelling: Owner: Permanent Address: Telephone No.: Home: If not an individual, type of Business Entity: Legal Agent: Address: Telephone No.: Business: Local Agent*: Permanent Address: Telephone No.: Home: Type of Dwelling: Single Family Required Attachments: Deed, Land Contract, etc. Information on Units Parking Information
RENTAL PERMIT APPLICATION
Initial Permit Renewal Permit
(If multiple-unit dwelling, may list range of addresses or attach additional sheet)
DOB
Business:
(e.g., Corporation; Trust; Partnership)
Fax: Corp. ID# Capacity* *e.g. Corporate Resident Agent, Managing Partner, Trustee
DOB
Fax: DOB
* Required where individual owner does not live within Calhoun County
Business:
Fax:
Two Family
Multiple Family
No. of Units
Attached Attached Attached Attached Attached
CERTIFICATION
Previously Accepted and Unchanged Previously Accepted and Unchanged Previously Accepted and Unchanged (Required if business entity is registering) (Required if business entity is registering)
Most recent corporate annual report filed with state of Michigan Certificate of Trust Existence, Proof of Partnership, etc.
By my signature, I hereby make application for a rental permit for the above premises and/or accept responsibility for the above premises under the terms of the City Code, and agree to allow City officials and/or appointees to enter and perform inspections as required by the Code of the City of Battle Creek in the manner permitted by said Code. I certify that insurance coverage for the structural loss or damage, and premises liability for personal injury exists and shall be maintained on the licensed property. I authorize the person I have designated in this application (if any) as my legal agent.
Signature of Owner Signature of Legal Agent Signature of Local Agent
Rev. 9/07
Date Date Date
RENTAL PERMIT APPLICATION PAGE TWO
FOR OFFICIAL USE ONLY
Received by: Cash Application: Complete Check #: Deficient Date: Amount:
App. Served with Notice of Deficiency by: In person If Applicable: Deficiencies Cured: Date: Previous Permitee: Verified by: Anniversary Date of Current Permit: Yes Compliance? Yes No Yes No No By Mail Date:
Any outstanding OTR’s, Terms & Conditions, Sanctions: Date of Last Annual Inspection: Delinquent City Fees, Fines, etc.: Action: Zoning Inspection Complete: Permit: Granted Denied By: Served by: In person Notes: By first class mail Type: Full
Code Inspection Complete: Conditional
Date: Date:
Rev. 9/07