INSTRUCTIONS: Applicants requesting Fair Housing Amendments Act accommodations to City of Long Beach codes
or procedures must complete the following information in full. Please Print clearly or type all answers; use additional
paper if necessary. Provide copies of all relevant permit applications, refusals and building plans, as well as copies of any
county, state or federal licenses currently active or required for the proposed use of the property.
1. Name of Applicant Telephone Number ( )
Applicant’s Address
2. Are you a Disable Person Within The Meaning of The Federal Fair Housing Act or do you Represent a Disabled Person
Covered by the Act: Yes No?
Location of Property?
3. Does this Request Relate to an: individual group home?
If this request relates to a group home, state:
(a) the name of the group home:_______________________________________
(b) The current number of residents in the group home:_____________________
(c) The proposed number of residents for the group home:__________________
(d) The current number of staff members for the group home:________________
(e) The proposed number of staff members for the gro
up home:______________
(f) Whether the group home will provide housing for adults or minors:_________
4. Name of Property Owner: Telephone Number ( )
Address of Property Owner:
5. What Type of Building Is The Subject of The Request For Accommodation:
single family resid
ential duplex apartment building other ____________________________
6. a. Check any code accommodations requested: Building Zoning Land Use
Other ________________________
b. Specify any request accommodation and describe why it is ne
cessary: ________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_
____________________________________________________________________________________________________
c. Specify any alterations to the property:
___________________________________________________________________
_____________________________________________________________________________________________________
Return form to: Long Beach City Hall, 411 W. Ocean Blvd. 2
nd
Floor, Long Beach, CA 90802
Fa
ir Housing Amendments Act
Reasonable Accommodation Request Form
Development Services
Planning Bureau
411 West Ocean Boulevard, 2nd Floor, Long Beach, CA 90802
562.570.6194
