Form Hcd 204 – Fill Out and Use This PDF

APPLICATION INSTRUCTION SHEET FOR PERMIT TO OPERATE

This is an application for a permit to operate an employee housing facility. Please complete the application form accurately, sign and date it, and return it with the appropriate fees. BEUSURE TO MAKE A COPY FOR YOUR RECORDS.

1.Enter the calendar year(s) within which you intend to operate the facility; enter the dates the facility will be occupied; check the appropriate box(es) for the type of permit you are applying for.

2.Enter the name of the facility and the facility’s ID if known.

3.Enter the address or location of the facility.

4.Check the appropriate box if the facility is located within the unincorporated area of the county or within an incorporated city and list the name of the county.

5.Enter the name and telephone number of the facility’s operator.

6.Enter the MAILING address of the facility’s operator.

7.Enter the name and telephone number of the legal owner of the property where the facility is located.

8.Enter the mailing address of the legal owner of the property and indicate whether this is a new owner.

9.Enter theU number of toilets, showers and lavatories provided for men and women. Indicate whether you intend to provide a mess hall or mess hall kitchen, community kitchen or none if no cooking facilities are available..U U NOTE:U A certificate of approval is

requiredUannually from the Local Health Department for a mess hall or mess hall kitchen.

10.Enter the numberUfor the appropriate type of housing units you intend to provide for employee use.

11.Enter the numberUof employees that will be housed in each type of housing unit.

12.Enter theU number of mobilehome/recreational vehicle lotsU you intend to provide for employee owned mobilehomes and/or recreational vehicles.

13.Total the numberUof employeesU from line 11UU and total numberUof lotsU provided from line 12U.U

Calculate the permit fee by adding the total number of employeesUU from line 11U,U and the total number of mobilehome/recreationalUvehicle

lotsU from line 12U,U and multiply x $27.00. Add the permitUfee ofU$200.00. (Example, the permit fee for 6 employees is $362.00, which is calculated 6 x $27.00/per employee equals $162.00, plus $200.00,U U totals $362.00. The fee for 6 employees and 6 mobilehomes/recreational vehicle lots is $524.00, which is calculated 6 x $27.00/per employee = $162.00, plus 6 x $27.00 per lot = $162.00, plus $200.00 totals $524.00.

14. If you already have a permit to operate for the current year and the number of employees housed and/or the number of lots provided

increase, or there is a change in ownership you must file an amendedUpermit to operate.UInclude the amended permit fee of $20.00, plus the $27.00 fee for each additional employee and/or lot.

•DATE,UPRINT YOUR NAME, SIGN THE FORM AND ENTER YOUR TITLE.

•STATE LAW REQUIRES THAT YOU FILE THE APPLICATION FOR PERMIT TO OPERATE AT LEAST 45 DAYS PRIOR TO THE DATE OF INITIAL OCCUPANCY. THEUAPPLICATION MUST BE COMPLETED AND THE REQUIRED FEES PAID TO BE ACCEPTED.

INCOMPLETE APPLICATIONS MAY BE RETURNED.

•WHEN WE RECEIVE YOUR COMPLETED APPLICATION AND FEES, A DEPARTMENT REPRESENTATIVE WILL CONTACT YOU TO SCHEDULE AN INSPECTION. IF THE FACILITY MEETS THE MINIMUM REQUIREMENTS OF THE EMPLOYEE HOUSING ACT, YOU WILL RECEIVE A TEMPORARY PERMIT TO OPERATE, WITH A PERMANENT PERMIT TO OPERATE TO FOLLOW.

•DOUBLE FEES ARE REQUIRED IF YOU ARE FOUND OPERATING WITHOUT A PERMIT.

•TENUTIMES THE FEES ARE REQUIRED IF YOU ARE FOUND OPERATING WITHOUT A PERMIT FOR A SECOND OR SUBSEQUENT

TIME WITHIN A FIVE YEAR PERIOD.

•IfUyou have any questions regarding the completion of this application, please direct your inquires to:

DepartmentUof Housing and Community Development, Employee Housing Program at (916) 445-9471.

HCD 204 (REV 1/11) SIDE 2