===== PAGE 1 ===== # APPLICATION FOR PERMIT TO OPERATE MOBILE HOME PARK OR SPECIAL OCCUPANCY PARK 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

Section 2. LOT INFORMATION Number of Lots Conditional Uses

Section 3. PART 3 FORM ORMATION
Number of Lots	Conditional Uses
Mobilehome Lots	Number of lots with an electrical system designed exclusively for:
Special Occupancy Lots with Drains	☐ 50 amperes	☐ 30 amperes
Special Occupancy Lots without Drains	☐ 30 amperes	☐ Other
Total Lots	☐ Other	☐ Other
Section 3. PARK INFORMATION — This section MUST be completed.
Park Name		Telephone
Location
Street Address—Do NOT use P.O. Box
City	State	County
☐ Incorporated City	☐ Unincorporated Area

### Section 4. OWNER, OPERATOR, AND MANAGER INFORMATION Owner Name ___ Mailing Address ___ City State Zip Email Address Telephone ___ I am a ferent than Owner (If different than Owner) Mailing Address ___ Number and Street or P.O. Box Number and Street or P.O. Box Email Address Telephone root(ame) Hire Date (If different than Operator) Address ___ City State Zip Number and Street or P.O. Box _____ 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___ Date City Signature (required)___ Printed Name___ HCD MP 500A (Rev. 03/24) DEPT USE ONLY: Inspector Signature_____ Date_____ ===== PAGE 2 ===== # INSTRUCTIONS Complete sections 1 through 5. Submit the appropriate fees and information required as specified in Health and Safety Code, division 13, parts 2.1 or 2.3 and California Code of Regulations, title 25, chapter 2 or 2.2 to the LOCAL ENFORCEMENT AGENCY for your park. ## Park ID No Enter the park identification number issued by the California Department of Housing and Community Development. If this is an original application or you have not been assigned a park identification number, leave this blank. ### Section 1. TYPE OF PERMIT REQUESTED Original—Check this box if this is the original request (newly constructed park) for a Permit to Operate. Amended—Check this box if this is a request for an amended Permit to Operate. Type of Amendment—Indicate the type of change being reported. If transferring ownership of the park, a recorded property deed with the new owner's name is required to be submitted with the application per California Code of Regulations (CCR), title 25, sections 1006.5 and 2006.5. When there is a change in the number of lots, enter the total number of lots in the space provided in Section 2. The addition of lots to an existing park requires local approvals in accordance with CCR, title 25, sections 1032 and 2032. Type of Park—Check the appropriate box to indicate the type of park for which the Permit to Operate is being requested. For combination parks, more than one box may be checked. Special Occupancy Park Designation—If applicable, check the appropriate box to indicate the type of special occupancy park. See CCR, title 25, section 2118 for special occupancy park designation information. ### Section 2. LOT INFORMATION Number of Lots—Provide the total number of lots within the park for each category listed. If a category does not apply, leave it blank. Enter the total number of lots in the space provided. This is the number of lots that will be shown on the Permit to Operate. Do NOT add lots or change existing categories without submitting approvals from the local jurisdiction in accordance with CCR, title 25, sections 1032 and 2032. Conditional Uses—Check the appropriate box to indicate any conditional uses. For lots constructed with electrical systems designed exclusively for units of 50, or 30 amperes (California Code of Regulations, title 25, section 1142). These lot numbers will appear on the Permit to Operate. Enter any other conditions on the use of the park as defined in Health and Safety Code sections 18205, 18300.1, 18862.13 and 18865.1. ### Section 3. PARK INFORMATION — This section MUST be filled in completely Enter the name of the park as it should appear on the Permit to Operate. Enter the park telephone number and location of the park. This is the physical address, do NOT enter a P.O. Box or route number. Check the appropriate box to indicate if the park is located in an incorporated city or unincorporated area. ### Section 4. OWNER, OPERATOR, AND MANAGER INFORMATION Enter the name, mailing address, email address, and telephone number of the park owner, park operator if different than owner, and on-site property manager if different than operator. Enter the manager's hire date. ### Section 5. OWNER CERTIFICATION The signature of the park owner is required, along with the owner's printed name. Enter the date and location the document is signed.