VILLAGE OF BELLWOOD
APPLICATION
MULTIPLE-FAMILY DWELLING OR
SINGLE-FAMILY DWELLING UNIT FOR RENT LICENSE
(Please type or print clearly)
COMPLETE NAME:__________________________________________________________________
BUILDING ADDRESS:________________________________________________________________
CITY:___________________ STATE:__________________ ZIP:______________________:
NAME:_______________________ BIRTH DATE:__________________
ADDRESS:____________________________________________________________________
CITY:_________________________ STATE:________________ ZIP:_______________
TELEPHONE NUMBERS: WORK____________ HOME______________
NAME:____________________BIRTH DATE:______________________
ADDRESS:____________________________________________________________________
CITY:________________________ STATE:_____________ ZIP:____________________
TELEPHONE NUMBERS: WORK___________________ HOME________________
If the owner is a land trust, please attach to this application a certified copy of a trust disclosure, including the name and address of each person(s) holding a beneficial interest and/or power of direction therein. (§ 124.03(A))
2. In the event that the owner of the multiple-family dwelling or single-family dwelling unit for rent resides outside the corporate limits of the village, the owner shall appoint a managing agent that (§ 124.16(G)):
1. Has an office at the multiple-family dwelling with regular business hours; or
2. Lives at the multiple-family dwelling and has regular business hours thereat; or
3. Has an office within the corporate limits of the village with regular business hours.
A managing agent shall be authorized to receive notices and process on behalf of the owner.
MANAGING AGENT (§ 124.04(B)):
NAME:________________________________BIRTH DATE:__________________________
ADDRESS:____________________________________________________________________
CITY:____________________________ STATE:___________________ ZIP:______
TELEPHONE NUMBERS: WORK___________________ HOME______________________
3. If the Managing Agent is other than a natural person, please fill out the following section:
REGISTERED AGENT OR PERSON ASSIGNED TO THE MULTIPLE-FAMILY DWELLING OR SINGLE-FAMILY DWELLING UNIT FOR RENT (§ 124.04):
NAME: _________________________________ BIRTH DATE:_____________________
ADDRESS: ___________________________________________________________________
CITY:______________________ STATE:__________________ ZIP:_____________
TELEPHONE NUMBERS: WORK______________________ HOME_____________
Every owner shall report to the Village Clerk any change in the designation of any agent, at least seven days prior to such change (§ 124.16(K)).
Please attach to this application, a copy of the written management agreement between the owner and the managing agent. If no written agreement exists, please attach an executed statement setting forth the terms of the managing agents authority to rent, manage, make expenditures. (§ 124.03(C))
4. JANITOR, ENGINEER OR MAINTENANCE PERSON(S) IN CHARGE OF THE MAINTENANCE OF THE MULTIPLE-FAMILY DWELLING OR SINGLE-FAMILY DWELLING UNIT FOR RENT AND ITS HEATING, COOLING, PLUMBING AND ELECTRICAL SYSTEMS. (§ 124.03(D))
NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
CITY:_______________________________ STATE:_________________ ZIP:__________
TELEPHONE NUMBERS: WORK_____________________ HOME________________
NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
CITY:__________________________ STATE:__________________ ZIP:_____________
TELEPHONE NUMBERS: WORK____________________ HOME____________________
Attached to the application shall be a statement of the janitor(s) or engineer(s) authority to maintain and repair the multiple-family dwelling or single-family dwelling unit for rent and its systems, including emergency repairs.
PERSON(S) RESPONSIBLE FOR MAINTAINING THE (EXTERIOR) COMMON AREAS, INCLUDING PARKING LOTS, SIDEWALKS, LANDSCAPING, ETC.:
NAME:______________________________ BIRTH DATE:___________________________
ADDRESS:____________________________________________________________________
CITY:__________________________ STATE:______________________ ZIP:___________
TELEPHONE NUMBERS: WORK_________________________ HOME_______________
5. PERSON(S) OTHER THAN THOSE LISTED ELSEWHERE ON THIS APPLICATION, IF ANY, HAVING AUTHORITY TO MAKE ANY DECISION WITH RESPECT TO THE MANAGEMENT OR MAINTENANCE OF THE MULTIPLE-FAMILY DWELLING OR SINGLE-FAMILY DWELLING UNIT FOR RENT (§ 124.03(E)):
NAME:___________________________ BIRTH DATE:___________________________
ADDRESS:___________________________________________________________________
CITY:____________________________ STATE:________________ ZIP:________________
TELEPHONE NUMBERS: WORK___________________ HOME_____________________
Please attach to this application, a written statement of this person's authority to manager, lease and/or maintain the multiple-family dwelling. (§ 124.03(E)):
6. COMPANY THAT SERVICES FIRE ALARM (§ 124.03(G)):
NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
CITY:___________________ STATE:_________________ ZIP:_____________________
TELEPHONE NUMBER:________________________________________________________
Please attach to this application a copy of the most recent fire alarm test results (§ 124.31)
7. COMPANY THAT SERVICES ELEVATOR (§ 124.19):
NAME:_______________________________________________________________________
ADDRESS:____________________________________________________________________
CITY:_________________ STATE:______________ ZIP:___________________
TELEPHONE NUMBER:________________________________________________________
8. Please attach to this application, a copy of a plan evidencing what improvements, renovation(s) and/or replacements are budgeted for the license year. (§ 124.03(H))
9. LICENSE FEES: Each application for license shall be accompanied by a license fee. The license fee shall be determined by the following schedule (§ 124.06):
Number of Units Owned | License Fee |
3-50
| $145 Per Building and $5 Per Unit
|
51-350
| $ 95 Per Building and $5 Per Unit
|
351 or more
| $ 90 Per Building and $5 Per Unit
|
The owner of a multiple-family dwelling containing more than one hundred (100) units may elect to pay the license fee in two (2) installments. The first installment shall be in the amount of fifty percent (50%) of the applicable license fee and shall be paid at the time of application. The balance of the applicable license fee shall be paid on or before July 1 of the license year. In the event the balance of the license fee is not paid on or before July 1 of the license year, the license shall be deemed to have terminated on July 2 of the license year, without further action by the village.
If a completed license application is not submitted together with the required license fee prior to January 1 in a given year, the license fee shall be increased by an additional twenty percent (20%); and further, the base license fee shall be increased by an additional twenty percent (20%) on the first additional twenty percent (20%) on the first of each subsequent month, until such time as a complete license application and the required license fee is paid.
NUMBER OF UNITS IN BUILDING:_____________________________________________
NUMBER OF BUILDINGS IN COMPLEX (if applicable):____________________________
Each building that is separated from another building by virtue of a fire wall or fire separation assembly, and has its own address, shall be considered a separate building.
LICENSE FEE:_______________________ AMOUNT ENCLOSED:________________
DATE:_________________________ CHECK NUMBER:_________________________
BALANCE DUE JULY 1 (If applicable):___________________________________________
10. I, the undersigned, hereby certify that:
(A) The information submitted in this application is an accurate representation of the facts at the date of application.
(B) I have read and understand Ordinance 93-66 of the village code pertaining to the licensing and inspection of multiple-family dwellings and single-family dwelling units for rent.
(C) I irrevocably consent to the village and its inspectors entry upon any and all portions of the licensed multiple-family dwelling or single-family dwelling unit for rent for purposes of making the inspections required and/or permitted under this chapter, including the right to inspect individual dwelling units. (124.04(J))
(D) I irrevocably consent and agree to pay all enforcement costs provided for by Title 3 Section 3-9-16 of the village code pertaining to the Licensing of Multiple-Family Dwellings and Single-Family Dwelling Units for Rent.
_____________________________________________________________________________________
Signature of Legal Title Holder § 124.03:
Please sign your name clearly on the first line and print your name clearly on the second line.
Signature:_______________________________ Date:___________________
Print Name Here:_________________________________________________
(Ord. 03-43, passed 8-20-03; Am. Ord. 03-59, passed 11-12-03)
VILLAGE OF BELLWOOD
SUPPLEMENTAL LEASE APPLICATION FOR MULTI-FAMILY DWELLING
OR SINGLE-FAMILY DWELLING UNIT FOR RENT
(Please type or print clearly.)
Building Address:___________________________________ Apartment #____________________
(1) FULL NAME (Please circle one: Mr. - Mrs. - Miss) BIRTH DATE__________________
DRIVER'S LICENSE #______________________________________
HOME PHONE #_______________________WORK PHONE #________________________
PRESENT ADDRESS__________________________________________________________
CITY______________________________________ ZIP CODE_____________________
PRESENT LANDLORD________________________________________________________
ADDRESS_____________________________ PHONE_________________________
REASON FOR LEAVING______________________________________________________
PREVIOUS LANDLORD_______________________________________________________
ADDRESS_____________________________ PHONE__________________________
REASON FOR LEAVING_______________________________________________________
PREVIOUS LANDLORD________________________________________________________
ADDRESS_____________________________ PHONE ________________________
REASON FOR LEAVING_______________________________________________________
(2) THE ONLY PERSONS TO OCCUPY DWELLING: (§ 124.16)
FULL LEGAL NAME BIRTH DATE RELATIONSHIP SOC. SEC. #
A)____________________________________________________________________________
DRIVER'S LICENSE # WORK # HOME #
______________________________________________________________________________
FULL LEGAL NAME BIRTH DATE RELATIONSHIP SOC. SEC. #
B)____________________________________________________________________________
DRIVER'S LICENSE # WORK # HOME #
______________________________________________________________________________
FULL LEGAL NAME BIRTH DATE RELATIONSHIP SOC. SEC. #
C)____________________________________________________________________________
DRIVER'S LICENSE # WORK # HOME #
______________________________________________________________________________
FULL LEGAL NAME BIRTH DATE RELATIONSHIP SOC. SEC. #
D)____________________________________________________________________________
DRIVER'S LICENSE # WORK # HOME #
______________________________________________________________________________
FULL LEGAL NAME BIRTH DATE RELATIONSHIP SOC. SEC. #
E)____________________________________________________________________________
DRIVER'S LICENSE # WORK # HOME #
______________________________________________________________________________
**THE MAXIMUM OCCUPANCY OF ANY DWELLING UNIT SHALL BE TWO (2) PERSONS PER BEDROOM. STUDIO APARTMENTS ARE LIMITED TO ONE (1) PERSON PER UNIT.
(3) EMPLOYER ADDRESS (CITY & ZIP)
______________________________________________________________________________
(4) SUPERVISOR PHONE #
______________________________________________________________________________
(5) VEHICLES OWNED BY PERSONS RESIDING IN UNIT (§ 124.16)
VEHICLE MAKE/MODEL/COLOR/YEAR_________________________________________
LICENSE PLATE #_____________________________________________________________
VEHICLE MAKE/MODEL/COLOR/YEAR ________________________________________
LICENSE PLATE #_____________________________________________________________
VEHICLE MAKE/MODEL/COLOR/YEAR_________________________________________
LICENSE PLATE #_____________________________________________________________
VEHICLE MAKE/MODEL/COLOR/YEAR_________________________________________
(6) PERSON(S) TO NOTIFY IN CASE OF EMERGENCY (§ 124.16)
NAME & ADDRESS____________________________________________________________
EMERGENCY CONTACT PHONE #______________________________________________
NAME & ADDRESS____________________________________________________________
EMERGENCY CONTACT PHONE #______________________________________________
(7) I, THE UNDERSIGNED, HEREBY CERTIFY THAT THE INFORMATION SUBMITTED IN THIS APPLICATION IS AN ACCURATE REPRESENTATION OF THE FACTS AT THE DATE OF THE APPLICATION. (§ 124.16)
DATE_____________ SIGNATURE________________________________________
DATE_____________ SIGNATURE________________________________________
*PLEASE ATTACH A COPY OF DRIVER'S LICENSE AND WORK ID (if any) TO THIS APPLICATION. (§ 124.16)
(Ord. 03-43, passed 8-20-03; Am. Ord. 03-59, passed 11-12-03)