I hereby request an Occupancy Permit for ADDRESS:*

Are you applying for a New or Updating your occupancy permit?*

NEW

UPDATE

Date of Proposed Occupancy *

Applicant(s)/Lessee(s) requesting permit:*

Place of Employment *

Phone Number of Employer*

Place of Employment

Phone Number of Employer

PLEASE LIST ALL PERSONS WHO WILL OCCUPY THE DWELLING UNIT:

Name*

Date of Birth*

Relationship in Household*

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Name

Date of Birth

Relationship in Household

Will any part of the residence be used to run a business (If yes, a business license is required)*

Yes

No

If Yes, what type of business?

Buying or Renting

Renting $65

Buying $40

Landlord Name

Address

Phone Number

I/We hereby certify that I/we am the proposed occupant(s) and that the answers contained herein are true and accurate in all respects to the best of my/our knowledge and belief. I/we further certify that I/we understand that this is an APPLICATION ONLY and that it is unlawful for me/us to occupy said dwelling unit until an approved Occupancy Permit shall have been obtained from the City of Black Jack, Missouri

Signature of Applicant*

Phone Number*

Date*

Signature of Applicant

Phone Number

Date

OCCUPANCY PERMITS FEES MAY NOT BE REFUNDABLE

Email all supporting documents to deputycourtclerk@cityofblackjack.com

Driver's License
Marriage License
Birth Certificates
Copy of lease if renting/leasing