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 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

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