New Renewal

Single Family Home Detached Unit Apartment Duplex Condo Two Family Mobile Home Twin Other

Yes No

Move in Date

Registration Type

Zone

Lock Box #

Property Type *

# of Bedrooms

Property Parcel ID

Lockbox Location

If Other

Is there a Signed Lease for all Tenants?

Property Details

# of Dwelling Units *

Address *

Corporation Individual LLC Partnership Other

Landlord Tenant

Owner Realtor Other

Address

City, State, ZIP *

Email *

All Persons listed on title of property must be included on this form. If property is held in Trust, Attach names of all beneficial interest holders pursuant to requirements of State Statutes.

Email

Ownership %

Name

Property Owner

Type *

Mailing Address *

Realtor or Agent Details

Phone can receive text messages?

Phone #

If the owner resides outside a 35 mile radius from LaSalle, you must designate a local Agent (within 35 miles of LaSalle) to accept property maintenance and notice/service responsibility. (P.O. Box Not Acceptable).

Please specify additional owner details below.

Responsible for yard maintenance?

Phone # *

Business Name

Name *

Phone # *

City, State, ZIP

Emergency Contact Person Is *

Name *

Emergency Contact

Email

Attachments

Fee Schedule

Fee Due

Please attach any necessary documentation below.

Certification

I the undersigned, hereby certify that:

The information submitted in this application is an accurate representation of the facts on the date of the application. The registration/license fee does not constitute official licensing until compliance with all the provisions of the Property Maintenance Code has been verified through inspection by authorized personnel.

Applicant Signature *