Sample Permit Application
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Borough of Wharton — Rental Compliance
License
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1.
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Rental dwelling unit location
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Block:
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Lot:
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Zone:
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2.
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Property owner(s):
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Name:
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Address:
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Phone No.
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3.
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Affidavit of variance(s):
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Identify any previously granted variance(s)
for this property. Provide date variance granted and nature of variance
granted:
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4.
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Name(s) of renter(s)
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Address of renter(s)
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Telephone No. of renter(s)
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5.
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Number of residents living in dwelling unit:
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6.
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Maximum occupancy:
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(Bedroom with 1 person — minimum 70 square
feet)
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(Bedroom with 2 or more persons — minimum
50 square feet per person)
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7.
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Total number of rental units on property:
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8.
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Number of off-street parking spaces available
per unit:
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For Official Use
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Housing Officer approval:
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Date application received:
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Permit application approved: Yes _____ No_____
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Comments/Reasons for Refusal:
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I, ______________________, Property Owner(s)/Agent
of the premises identified herein, do hereby attest that the information
provided on this application is true and that any change in the number/type
of residential units or number of tenants will be reported to the
Borough of Wharton immediately to facilitate up-to-date Borough records.
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Signature:
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Owner(s)/Agent
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Date:
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Sworn to and subscribed
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Before me this
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Day of _________________ 20___.
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Notary Public
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