Certificate of Use for Rental Dwelling Units

License and Inspection

Rental Dwelling Information

Dwelling Type *

Address of Dwelling Unit(s) *

Number of Occupants Residing *

Number of Units to be Inspected *

Provide Square Footage of the Living Room, Dining Room, and Each Bedroom

	Room Type	Square Footage
1	Room Type *	Square Footage *

Room Type

Square Footage

Export Clear Add new row

Room Type *

Square Footage *

	Room Type	Square Footage
1	Room Type *	Square Footage *

Room Type

Square Footage

Export Clear Add new row

Room Type *

Square Footage *

List the Full Name of the Occupants Residing in the Dwelling Unit

Unit 1/Single Family Home *

Unit 3

Unit 4

Purpose of Inspection (Indicate Yes or No for all that apply)

Annual Inspection *

Change of Ownership *

Change of Lease

Reoccupation of Vacant Unit(s) *

Annual Inspection Fee

Change of Owner Fee

Change of Lease Fee

Reoccupation Fee

Annual Included

Change of Owner Included

Change of Lease Included

Reoccupation Included

Annual Inspection Amount

Change of Owner Amount

Change of Lease Amount

Reoccupation Amount

Owner/Agent Information

Owner Name *

Owner Phone Number *

Owner Address *

City *

State *

Zip Code *

Landlord, Realtor, Manager, or Responsible Agent Information

Agent Name *

Agent Phone Number *

Agent Address *

City *

State *

Zip *

Buyer Information

Buyer Name *

Buyer Phone Number *

Buyer Address *

City *

State *

Zip *

Fees

Permit Number

Use the Drawing Tool to Sign the Form in the Box Below

Applicant Is: *

Owner Landlord/Relator/Manager/Responsible Agent

Applicant Signature

Application Date *

Applicant Signature

Application Date *

Applicant Email Address *

Payment Information

Payment of fees for this application will be requested via email once your submission has been reviewed.  Please verify that emails from donotreply@springfielddel.co are not sent to your spam/junk mail folder.  The email will contain a link to this form allowing you to make a secure payment by credit card.  The amount shown below is an estimated amount and may be adjusted once your submission is reviewed.

Payment Amount Due

Certificate of Use for Rental Dwelling Units

License and Inspection

Rental Dwelling Information

Owner/Agent Information

Landlord, Realtor, Manager, or Responsible Agent Information

Buyer Information

Payment Information

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