ENFORCEMENT AGENCY
ENFORCEMENT AGENCY
APPLICATION FOR PERMIT TO OPERATE MOBILE HOME PARK OR SPECIAL OCCUPANCY PARK Park ID #___
Park ID
Section 1. TYPE OF PERMIT REQUESTED
☐ Original☐ Amended (Choose type below)
Type of Amendment:☐ Transfer of Owner / Operator / Manager (Transfer of owner requires recorded property deed with new owner's name)
☐ Change of Name or Address
☐ Change in Number of Lots (Additional lots requires local approvals and inspection)
Type of Park:☐ Mobilehome Park ☐ Special Occupancy Park (if applicable, select appropriate designation below)
Special Occupancy Park Designation (if applicable):
☐ Temporary Special Occupancy Park ☐ Incidental Camping Area ☐ Tent Camp
Original
Amended (Choose type below
Transfer of Owner / Operator / Manager (Transfer of owner requires recorded property deed with new owner’s name
Change of Name or Address
Change in Number of Lots (Additional lots requires local approvals and inspection
Mobilehome Park
Special Occupancy Park (if applicable, select appropriate designation below
Temporary Special Occupancy Park
Incidental Camping Area
Tent Camp
Section 2. LOT INFORMATION Number of Lots Conditional Uses
Section 3. PART 3 FORM ORMATION
Number of Lots Conditional Uses
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Mobilehome Lots Number of lots with an electrical system designed exclusively for:
50 amperes
Special Occupancy Lots with Drains
50 amperes
Special Occupancy Lots with Drains ☐ 50 amperes ☐ 30 amperes
Special Occupancy Lots without Drains [1]
Number of lots with an electrical system designed exclusively for [2]
Special Occupancy Lots without Drains ☐ 30 amperes ☐ Other
30 amperes
Special Occupancy Lots without Drains [2]
Number of lots with an electrical system designed exclusively for [3]
Total Lots ☐ Other ☐ Other
Other
Section 3. PARK INFORMATION — This section MUST be completed.
Park Name Telephone
Park Name
Telephone
Location
Location
Street Address—Do NOT use P.O. Box
City State County
Zip
City
State
County
☐ Incorporated City ☐ Unincorporated Area
Incorporated City
Unincorporated Area
Section 4. OWNER, OPERATOR, AND MANAGER INFORMATION
Owner Name ___
Owner Name
Mailing Address ___
Mailing Address
City State Zip
Email Address Telephone ___
Email Address
Telephone
I am a
Operator Name
(If different than Owner)
ferent than Owner
Mailing Address ___
Mailing Address
Number and Street or P.O. Box
Number and Street or P.O. Box
Email Address Telephone
Email Address
Telephone
root(ame) Hire Date
On-Site Property Manager Name
Hire Date
(If different than Operator)
Address ___
Mailing Address
City State Zip
Number and Street or P.O. Box
_____ Telephone___
Email Address
Telephone
Section 5. OWNER CERTIFICATION
As owner of the park described above, I agree to all necessary inspections required to obtain a Permit to Operate. I also agree that this park shall be operated and maintained in accordance with Health and Safety Code, division 13, part 2.1 and/or part 2.3 and the applicable provisions of California Code of Regulations, title 25, chapters 2 and/or 2.2. I certify under penalty of perjury under the laws of the State of California, that the information provided in this application is true and correct.
Executed on___ at___
Executed on
Date
City
Signature (required)___ Printed Name___
Signature (required
Printed Name
HCD MP 500A (Rev. 03/24) DEPT USE ONLY: Inspector Signature_____ Date_____
DEPT USE ONLY: Inspector Signature
Date