Application for Mobile Home Park License

Application for Mobile Home Park License
Park Name*
Number of Lots*
Fee*
Name of Applicant*

First NameLast Name
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location of Mobile Home Park *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Land Owner, (if leased, lease term and expiration date)*
Current Mobile Home Park plan to be submitted with the application showing the Park layout, numbered spaces, roadways, service facilities, ect., in accordance with Chapter 4 of Town of Somers Ordinances or Chapter 4 of the Village of Somers Ordinances, whichever applicable. *

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Please attach plan Cancelof
Number of Mobile Home site or spaces being applied for under this permit*
Minimum lot size, exclusive of roadways or park service areas for spaces being applied for*
Has applicant previously operated a Mobile Home Park?*

YesNo
Has applicant at any time been convicted in this State or elsewhere of any crime?*

YesNo
If yes, nature of crime and jurisdiction where crime was committed
Is applicant a corporation?*

YesNo
If yes, list State of Incorporation, names and addresses of Officers and Directors of Corporation
Name of Park Operator*

First NameLast Name
Address of Park Operator

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Park Operator

Area CodePhone Number
Email of Park Operator*
example@example.com
Brief description of water supply and sanitary facilities (municipal, private, ect.)*
Signature*

Clear
Date Signed*

MonthDayYear
Return application and fee to:

Village/Town of Somers

Village/Town Clerk

PO Box 197

Somers, WI 53171
FOR OFFICE USE ONLY
Date application received*

MonthDayYear
Date of Board action*

MonthDayYear
Building Inspector Date*

MonthDayYear
Fire Inspector Date*

MonthDayYear
Date Issued*

MonthDayYear
Plan Commission referral date

MonthDayYear
(If Required)
Should be Empty: