1. ADDRESS OF RENTAL PROPERTY _____________________________________
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2. NAME OF OWNER _____________________________________
3. ADDRESS OF OWNER _____________________________________
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4. TELEPHONE # OF OWNER _____________________________________
5. NAMES OF TENANTS _____________________________________
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_____________________________________
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6. TELEPHONE # OF TENANT _____________________________________
7. AGES OF CHILDREN _____________________________________
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8. SIGNED _____________________________________
9. DATE _____________________________________
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For Office Use Only
__________ $35.00 registration
Fee __________ $10.00 Re-inspection Fee
__________ Date of inspection __________ Time of inspection
__________ Date of re-inspection __________ Time of re-inspection