Application for Mobile Home Park License

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

First Name Last Name
Address of Applicant *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Location of Mobile Home Park *

Street Address

Street Address Line 2

City State / 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 Cancel of
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? *

Yes No
Has applicant at any time been convicted in this State or elsewhere of any crime? *

Yes No
If yes, nature of crime and jurisdiction where crime was committed
Is applicant a corporation? *

Yes No
If yes, list State of Incorporation, names and addresses of Officers and Directors of Corporation
Name of Park Operator *

First Name Last Name
Address of Park Operator

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number of Park Operator

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

Clear
Date Signed *

Month Day Year
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 *

Month Day Year
Date of Board action *

Month Day Year
Building Inspector Date *

Month Day Year
Fire Inspector Date *

Month Day Year
Date Issued *

Month Day Year
Plan Commission referral date

Month Day Year
(If Required)
Should be Empty: