Supplementary Statement
To Application for Permit To use one Family Dwelling for
Mother/Daughter Residence
Application Number _______________________________________________________________
Address ________________________________________________________________________
Occupancy of Primary Housekeeping Unit
Name
Age Relationship to Residential Owner
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
Occupancy of Housekeeping Unit Served by Second Kitchen
Name Age Relationship to Residential Owner
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
__________________________ _______ _________________________________________
The following questions must be answered:
1. Will separate entrances be assigned to each housekeeping unit? _________________________
2. Will there be separate gas, electric or water meters? __________________________________
3. With there be separate doorbells or mailboxes? ______________________________________
4. Indicate number of vehicles to be parked at premises _________________________________
5. Indicate all phone listings _______________________________________________________
_____________________________________________________________________________
Statement:
I do hereby state that I am the Fee Resident Owner or contract resident vendee of the subject
premises; that I have read the contents of the foregoing and know the same to be true and correct in
every respect.
Name __________________________________________
Phone__________________________________________
Sworn to before me this ____________________
Day of ___________________________ 20____
________________________________________
Notary Public
