Residential Commercial Mixed Use

Initial Registration First Renewal Second Renewal Subsequent Renewal De-Registration Status Change

Abandoned Actively being advertised rent Actively being advertised sale Occupied Under Construction Vacant

Yes No

Yes No

On Off

On Off

On Off

Initial Registration

Attachments

Email *

Water

Agent Name

Address

First Renewal

Status *

Block *

Property Identified As

Subsequent Renewal

City, State, ZIP

Property Owner Information

Phone #

City, State, ZIP

I, the undersigned, hereby affirm that i am duly authorized to act on behalf of all ownership interests in the above-referenced property. I hereby attest/swear that the information contained herein is accurate and complete to the best of my knowledge. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment under the violations section of §132-91.le.

Property Type *

If this is a Status Change, please provide the reason and attach any relevant documentation below:

The final fee determination will be sent to after review.

Name

Number of Stories

Name

Email *

$3000.00

Property Details

Fax #

$1500.00

Phone Number

Company Name

Person to Receive Certified Mail or Notices

Account Number

Email

Certification

Fee Schedule

Phone #

Assessment

Applicant Signature *

Address

Number of Garages

Financial Institution/Bank Information

City, State, ZIP *

Gas

Lot *

Registration Fee

Foreclosure Docket #

City, State, ZIP

Address *

Email

Fax #

City, State, ZIP *

Company Name

Phone # *

This list is suggested attachments to deregister.

• Active MLS listing for sale or rent of a property
• Permit issued by the Construction Office for work to be conducted
• Contractor invoice for work completed
• Signed contract from licensed contractor for work to be completed, estimated date of work required
• Proof of change of ownership/sale of property
• Other

Once reviewed, you will be advised if a fee exemption is possible based on the provided documentation.

Is this person the same as the Owner? *

Email

Company Name

Representative *

Mailing Address *

Name *

Agent/Representative

Property Address

Address *

Address

Unit #

Second Renewal

Utilities

$5000.00

Phone #

Registration Type *

$500.00

Phone # *

Maintenance Company

Is there a sign affixed to the property indicating the name, address & telephone number of the Owner and Owner’s Authorized Agent? *

Contact Agent

Electric

Date of Vacancy *

Square Footage *