Fillable Village of Newburgh Heights (Village of Newburgh Heights)

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Village of Newburgh Heights (Village of Newburgh Heights)

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Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
216-641-4654, newburgh-oh.gov, Monday-Thursday, 9am-3:30pm
2021/2022 Rental Permit Application
(Codified Ordinance Chapter 1353: Registration and Inspection of Rental Units)
Incomplete forms will not be accepted. Complete an application for each rental property.
Rental Property Information
RENTAL PROPERTY ADDRESS:
Is this Property Owner Occupied? Yes No
Are you a CMHA Landlord? Yes No
Type of Dwelling: Single-Family Two-Family Multi-Family
Number of Rental Units:
Number of Bedrooms per Rental Unit:
Monthly Rent Amount Per Unit:
Owner Information
Name:
Property Owner Address:
D. License/State ID # (attach copy):
City:
State:
Phone:
Alt. Phone:
Email:
Email Receipt/Report: Yes No
Property Management Information
Name of Property Management Company (if applicable):
Name of Primary Contact/Manager:
Proof of Consent (attach letter/contract): Yes No
*Real Estate Broker’s License is required in Ohio if property manager is going to lease, rent list, procure prospects or negotiate, assist,
operate, manage or rent any building or portion to the public as tenants. Custodians, janitors or caretakers are exempt.
Address:
City:
Zip Code:
Business Phone:
Primary Contact Phone:
Email Address of Primary Contact:
Tenant Information (include ALL persons living at the property in addition to on the lease)
NAME
UNIT
PHONE/EMAIL ADDRESS
Disclaimer for Rental Inspection
! I agree and consent to an inspection to be conducted by a designee of the Village of Newburgh Heights at the agreed upon date
and time as scheduled with the Housing and Building Department. I understand missed inspections may accrue a fee. I agree to
make all areas of the property accessible for inspection. I will schedule the required inspection within 30 days of applying for a
Rental Permit. I understand an inspection is required upon a change of tenant and will contact the Housing and Building Department
if a change occurs.
Applicant Signature:
Date:
Payment Information
Number of Units _______ x $150.00
Late Fee
$100.00
Renewal Year: 2022
Credit Card #:
EXP: CVS: Name (if different than above):
Cash/Check #:
Proof of Insurance: Yes
No
Property Taxes: Paid On-Plan
Date of Inspection:
Time:
The Rental Registration and Inspection fee is $150.00 per rental unit. Each Rental Permit/Renewal shall expire at the end of December 31
st
of the year
following the year in which the Rental Permit/Renewal was issued. Rental Permit/Renewal application and fees are due by March 31
st
. There shall be a
$100.00 fee assessed for no or incomplete applications and fees submitted past the due date. Fees are non-refundable.
Payment made online:
Ohio
$ 0.00
$ 0.00
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Village of Newburgh Heights (Village of Newburgh Heights)

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Completed 19 January 2021

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