Multi-Unit Rental Dwelling Permit Application

TOWN HALL OFFICE 2871 S. AFTON ROAD BELOIT, WISCONSIN 53511-8666 PHONE: 608-364-2980 FAX: 608-364-2986 www.town.beloit.wi.us

Fee: $40.00 (Per unit)

INSTRUCTIONS: This form must be completed in its entirety by the property owner and returned to the Town Hall office with the $40.00 fee (per unit) in order for your permit to be processed. Incomplete, incorrect, illegible and fraudulent applications will denied. A separate application must be completed for each building. Please PRINT clearly.

Property Information Address of Property to be rented: Apartment Numbers: Parcel Number:

City/ST/Zip:

6-2-

BELOIT WI 53511

Description of Property to be Rented Type of Building (circle one):

Duplex

Quad

Other (Describe):______________________

Year Building was Constructed:

Year Building was Converted for Rental :

Type, Number and bedroom area (square feet) of rental units in building: Efficienty Apartment One Bedroom Apartment Two Bedroom Apartment Three Bedroom Apartment

Number of Units Number of Units Number of Units Number of Units

__________ __________ __________ __________

Total bedroom area/unit __________ Total bedroom area/unit __________ Total bedroom area/unit __________

Other (describe) __________

Number of Units __________

Total bedroom area/unit __________

Number of Unenclosed Off-Street Parking Spaces Dedicated for the use of Occupants of this Building.

________

Is part of this building used for any other use (circle one)?

Yes

Number of Enclosed Off-Street Parking Spaces Dedicated for the use of Occupants of this Building:

_________

No

If yes, for what other purposes is this building used?_____________________________________________________

Property Owner Information Form of Ownership (circle one): Type of Ownership: (circle one):

Deed Individual

Purchase Contract Partnership

Land Contract

Other(describe): ___________________

Corporation

Other(describe):___________________

LLC

Name of all Owners (attach extra sheets if necessary). LAST NAME, FIRST NAME, MI : STREET ADDRESS:

CITY/STATE/ZIP:

Page 1 of 2

PHONE:

EMAIL:

Property Manager Information (must operate from a place of business within 25 miles of the Town of Beloit) If same as owner, please note. NAME:

STREET ADDRESS:

CITY/STATE/ZIP:

PHONE:

FAX:

EMAIL:

CERTIFICATIONS: I, the undersigned having made myself aware of the requirements of the Town of Beloit Code of Ordinances, as well as the conditions of the property that is the subject of this application, do hereby swear and affirm that the information contained in this application is true and correct to the best of my knowledge and furthermore, that: 1. The property has not been condemened. 2. Tenants are not required to waive any of the Landlord’s property maintenance responsibilities as a condition of any rental agreement. 3. The rental agreement for this property conforms to Chapter ATCP 134 of the Wisconsin Administrative Code. 4. The property is, and/or will be rented in compliance with Chapter 15-3, Fair Housing, of the Town of Beloit Code of Ordinances. 5. The rental dwelling unit confirms to the minimum standards contained in paragraph 6 of Chapter 15-8 and Chapter 15-5, Residential Property Maintenance Code, of the Town of Beloit Code of Ordinances. 6. There are no known fire hazards affecting the rental dwelling. 7. There are no past due property taxes, special assessments, fines, forfeits or municipal sewer and/or water bills related to the dwelling unit. I understand that any error, falsehood, and/or incomplete information contained in this application are cause for denial, or the rescinding of the permit applied for. Applicant’s Signature: ____________________________________________ Date:________________________ Printed Name:_____________________________ Date of Birth______________________________

Witness Signature:_________________________________________ Date:_________________________ Printed Name:______________________________________

FOR OFFICE USE ONLY:

Receipt No:_____________________________ Amount Paid: ________________________________________________ Date Paid:_____________________________ COPY: CODE ENFORCEMENT ORIGINAL: TOWN CLERK PAGE 2 of 2

Revised 12/19/16