Fillable Form 1: Application for [variation of] HMO (Houses (Rochdale Metropolitan Borough Council)

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Form 1: Application for [variation of] HMO (Houses (Rochdale Metropolitan Borough Council)

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1
Rochdale Borough Council
Application for [variation of] HMO (Houses in Multiple
Occupation) Licence
Please complete this form using
black
or
blue
ink only. Write clearly within the boxes provided.
If you do
not complete all of the relevant sections accurately and in full, the processing of the application may be
delayed and incur further charges.
Only complete this application form for a house in multiple occupation that requires a licence.
To
Rochdale Borough Council
Strategic Housing Services
Number One Riverside
Smith Street, Rochdale OL16 1XU
I/We apply for [variation of] a HMO Licence.
Dated
Signed
If you have ticked 'yes', please indicate below
which authority you have applied to or been
granted a licence by.
If you have ticked 'yes', please fill in the details
overleaf and go to part 2 unless any details in
previous applications have changed. If any
details have changed, please go to Part 1 and
complete all subsequent parts of the form.
If you have ticked 'no', please go to Part 1 and
complete all the necessary parts of the form, in
full.
If the property does not require a licence,
please complete the declaration overleaf and
return to the above address.
Have you applied for a HMO licence
within another authority?
Yes No
Reference
number:
Have you applied for a HMO licence for
another HMO within the area of
Rochdale Borough Council
Yes No
Address of HMO to be licensed:
Postcode:
Local Authority
Date granted
Please indicate which type of licence
application you are making
Application for a new licence
Variation of an existing licence
Please indicate the type of house for
which the application is being made
House in multiple occupation
Flat in multiple occupation
A house converted and comprising
only of self-contained flats
Please indicate how the HMO is
operating
HMO - bed-sits
HMO with shared facilities
Household with lodgers
A hostel, B&B or guesthouse
Supported lodgings
Other, please specify:
2
The following details are required from
applicants who have already submitted an
HMO licensing application form to enable the
council to find the records.
If the proposed licence holder is NOT the
person having control of the property, the
person having control of the property and the
proposed licence holder MUST sign the
following declarations.
I, as the person having control of the
property, hereby give my consent to the
above named being licence holder.
Name:
(please print)
Signature:
Date:
Please remember that for a HMO to require a
licence it must meet the following criteria:
1) have 3 storeys or more and;
2) 5 or more persons forming more
than one household and;
3) live in the dwelling as their main or
only residence.
If all the criteria are met, please complete the
form as required. If any of the criteria are not
met, please complete the following declaration
and return the application form to the address
on the front of this form.
Declaration: I confirm the above property does not require a HMO licence.
Name
(please print) :
Date:
Signature: Interest in property:
I consent to being named as the
proposed licence holder of the above
named property.
Name:
(please print)
Signature:
Date:
Details of the person having control of
the HMO
Title: Mr Mrs Miss Ms Other
Full name:
Address:
Postcode:
Telephone:
Details of the applicant
Title: Mr Mrs Miss Ms Other
Full name:
Address:
Postcode:
Telephone:
Details of the proposed licence holder,
if different from applicant
Title: Mr Mrs Miss Ms Other
Full name:
Address:
Postcode:
Telephone:
Details of the manager/managing agent,
if applicable
Title: Mr Mrs Miss Ms Other
Full name:
Address:
Postcode:
Telephone:
3
Section 1: Details of applicant
The applicant must be a named individual
1.1
Title:
Mr Mrs Miss Ms
Other
Full name:
Residential address:
P
roof of address:
Postcode:
Driving licence
Bank statement
Utility bill
Other
Business address:
(if applicable)
Proof of address:
Postcode:
Business rates Utility bill
Home tel no: Mobile tel no:
Work tel no:
Fax no:
e-mail address:
Date of birth:
Interest in property:
Owner
Manager Leaseholder
Other
1.2
Yes
No
1.3
Are you the proposed licence holder?
Yes
(please go to question 2.2)
No
(please go to question 2.1)
Part 1
–
Personal details
4
Section 2: Details of proposed licence holder
The proposed licence holder must be a named individual
2.1
Title:
Mr Mrs Miss Ms Other
Full name:
Residential address:
Proof of address:
Postcode:
Driving licence
Bank statement
Utility bill
Other
Business address:
(if applicable)
Proof of address:
Postcode:
Business rates Utility bill
Home tel no:
Mobile tel no:
Work tel no:
Fax no:
Email address:
Date of birth:
Interest in property:
Owner
Manager Leaseholder
Other
2.2
If the proposed licence holder is part of a company, partnership, charity or trust, please
indicate which and provide contact details of all directors, partners, trustees - please
use additional sheet(s) if more than 2. If not part of a company charity or trust, please go
to question 2.4.
Limited Company Partnership Charity
Trust
Limited Company/partnership/charity/trust name:
Registered Company/Charity No:
Director Partner
Trustee
Director
Partner
Trustee
Full name:
Full name:
Registered address: Registered address:
Postcode:
Postcode:
Telephone no:
Telephone no:
Fax no:
Fax no:
Email address:
Email address:
Date of birth:
Date of birth:
5
2.3
Please provide details of the Company Secretary/Senior Partner/Trust Secretary:
Title:
Mr Mrs Miss Ms
Other
Full name:
Company secretary
address:
Postcode:
Telephone no: Fax no:
Email address:
2.4
Please provide an address where all official correspondence should be sent. All partners
or trustees should sign their agreement to this address. This will be the address used on
the public register.
Name of person or company:
Correspondence address:
Postcode:
Telephone no:
Email address:
I, as a partner or trustee hereby give agreement to the above address being used for
all official correspondence and on the public register provided by
Rochdale Borough Council
Name:
(please print)
Signature:
Name:
(please print)
Signature:
Name:
(please print)
Signature:
2.5
Is the proposed licence holder a member of any landlords association or other professional
body? Please indicate which.
Organisation
Since
2.6
Is the proposed licence holder an accredited landlord in this or another authority? Please indicate
and provide details of the scheme operator.
Authority Scheme operator Since
2.7
Please list training courses or conferences attended - relevant to property management - by
the proposed licence holder.
Training course Date
6
Fit and Proper Person
The local authority must consider evidence whether the proposed licence holder,
and any person
associated or formerly associated with them
, whether on a personal, work or other basis is a fit and
proper person.
2.8
Has the
proposed licence holder
, or anyone
associated
with the proposed licence holder, ever accepted
a simple caution, previously known as a formal caution, from the Police or been convicted of an offence
(subject to the Rehabilitation of Offenders Act 1974) involving any of the following?
Proposed licence
holder
Associate
Yes
No
Yes
No
Fraud
Dishonesty
Violence
Drugs
Sexual Offences Act 2003, Schedule 3
2.9
Has the
proposed licence holder
, or anyone
associated
with the proposed licence holder, ever been
subject to unlawful discrimination proceedings relating to their business, (subject to the Rehabilitation of
Offenders Act 1974) involving any of the following?
Proposed licence
holder
Associate
Yes
No
Yes
No
Sex
Colour
Race
Ethnic or national origin
Disability
2.10
Has the
proposed licence holder
, or anyone
associated
with the proposed licence holder, ever accepted
a simple caution, been convicted of an offence or been served with Statutory Notices under any of the
following?
Proposed licence
holder
Associate
Yes
No
Yes
No
Housing Law
Landlord and Tenant Law
Environmental Protection Act 1990
Public Health Law
Health and Safety Law
Building Regulation or Planning Laws
2.11
Has the
proposed licence holder
, or anyone
associated
with the proposed licence holder, ever been
convicted for non-compliance of a Statutory Notice under any of the following?
Proposed licence Associate
holder
Yes
No
Yes
No
Housing Law
Landlord and Tenant Law
Environmental Protection Act 1990
Public Health Law
7
Health and Safety Law
Building Regulation or Planning Laws
2.12
Has the
proposed licence holder,
or anyone
associated
with the proposed licence holder, ever been in
control of a property subject to any of the following?
Proposed licence
holder
Associate
Yes
No
Yes
No
Control Order or Management Order
Where works have been carried out in default
A licence or registration certificate has been refused
Conditions of a licence or registration certificate have
been breached
2.13
A
licence holder
must have the financial arrangements necessary to ensure the property is properly
managed and maintained. Please answer the following questions.
Proposed licence
holder
Yes
No
Do you have the authority to repair and maintain the property and have the
financial arrangements necessary to repair the property?
Are you an undischarged bankrupt?
Are there any County Court judgments against you or any company of
which you are a director or secretary?
If you have answered 'yes' to any of the above questions, it is necessary for the c ouncil to
undertake a further 'fit and proper person' check on the proposed licence holder and anyone
associated with them. We will contact you to advise further.
Statutory declaration for release of information
To be completed by proposed licence holder:
All information provided will be treated in confidence and in accordance with the Data Protection
Act 1998. It will only be used to progress your application.
As part of our duty under the Housing Act 2004 we may have to share and/or check your information with
other agencies including the Police, Fire and Rescue Service, Office of Fair Trading, other local
authorities and other relevant departments within this Council, for example Council Tax, Revenues and
Benefits and Debtors.
Please sign and date the declaration below for us to progress your application.
I, as the proposed licence holder, hereby authorise any statutory body holding
information about me, which falls within the categories above, to provide information
on request by the council.
Name:
(please print)
Signature:
Date
8
Section 3: Details of manager or managing agent if different
from proposed licence holder
The proposed licence holder must be a named individual
3.1
Title:
Mr Mrs Miss Ms
Other
Full name:
Residential address:
Proof of address:
Postcode:
Driving licence
Bank statement Utility bill
Other
Business address:
(if applicable)
Proof of address:
Postcode:
Business rates
Utility bill
Home tel no:
Mobile tel no:
Work tel no:
Fax no:
Email address:
Date of birth:
Interest in property:
Owner
Manager Leaseholder
Other
3.2
If the manager or managing agent is part of a company, partnership, charity or trust,
please indicate which and provide contact details of all directors, partners, trustees -
please use additional sheet(s) if more than two. If not part of a limited company,
partnership, charity or trust, please go to section 4.
Limited Company Partnership Charity
Trust
Limited Company, partnership, charity, trust name:
Registered company/Charity number:
Director
Partner
Trustee
Director
Partner
Trustee
Full name:
Full name:
Registered address:
Registered address:
Postcode:
Postcode:
Telephone no:
Telephone no:
Fax no:
Fax no:
Email address:
Email address:
Date of birth:
Date of birth:
9
3.3
Please provide details of the company secretary, senior partner, trust s ecretary:
Title:
Mr Mrs Miss Ms
Other
Full name:
Company secretary
address:
Postcode:
Telephone no:
Fax no:
Email address:
3.4
Please provide an address where all official correspondence should be sent. All partners/
trustees should sign their agreement to this address. This will be the address used on the
Name of person or company:
Correspondence address:
Postcode:
Telephone no:
Email address:
I, as a partner or trustee hereby give agreement to the above address being used for
all official correspondence and on the public register provided by
Name:
(please print)
Signature:
Name:
(please print)
Signature:
Name:
(please print)
Signature:
3.5
Is the manager/managing agent a member of any landlords association or other professional
body? Please indicate which.
Organisation Since
3.6
Is the manager or managing agent accredited in this or another authority? Please indicate
and provide details of the scheme operator.
Authority Scheme Operator Since
3.7
Please list training courses/conferences attended - relevant to property management - by the
manager/managing agent.
Training course Date
10
The local authority must consider evidence whether the
manager or managing agent
is a fit and
3.8
formal caution, from the Police or been convicted of an offence (subject to the Rehabilitation of
Offenders Act 1974) involving any of the following?
Manager or agent
Yes
No
Fraud
Dishonesty
Violence
Drugs
Sexual Offences Act 2003, Schedule 3
3.9
Has the
manager/managing agent
, ever been subject to unlawful discrimination proceedings relating to
their business, (subject to the Rehabilitation of Offenders Act 1974) involving any of the following?
Manager or agent
Yes
No
Sex
Colour
Race
Ethnic or national origin
Disability
3.10
Has the
manager or managing agent
, ever accepted a simple caution, been convicted of an offence or
been served with Statutory Notices under any of the following?
Manager or agent
Yes
No
Housing Law
Landlord and Tenant Law
Environmental Protection Act 1990
Public Health Law
Health and Safety Law
Building Regulation or Planning Laws
3.11
Has the
manager or managing agent
, ever been convicted for non-compliance of a Statutory Notice
under any of the following?
Manager or agent
Yes
No
Housing Law
Landlord and Tenant Law
Environmental Protection Act 1990
Public Health Law
Health and Safety Law
Building Regulation and Planning Laws
11
If you have answered 'yes' to any of the above questions, it is necessary for the council to
undertake a further 'fit and proper person' check on the manager or managing agent. We will
contact you if we require any further information.
Statutory declaration of release of information
To be completed by manager or managing agent:
All information provided will be treated in confidence and in accordance with the Data Protection
Act 1998. It will only be used to progress your application.
As part of our duty under the Housing Act 2004 we may have to share and/or check your information with
other agencies including the The Criminal Records Bureau, Police, Fire and Rescue Service, Office of
Fair Trading, other local authorities and other relevant departments within this Council, for example
Council Tax, Revenues and Benefits and Debtors.
Please sign and date the declaration below for us to progress your application.
I, as the manager or managing agent, hereby authorise any statutory body
holding information about me, which falls within the categories above, to provide
information on request by the council.
Name:
(please print)
Signature:
Date
3.12
Has the
manager or managing agent
, ever managed a property, subject to any of the following?
Manager or agent
Yes
No
A Control Order or Management Order?
Where works have been carried out in default following service of a notice?
A licence or registration certificate has been refused?
Conditions of a licence or registration certificate have been breached?
3.13
Manager or agent
Yes
No
Do you have the authority to carry out any works required to the property?
Is there any financial limitation on the amount of work you can carry out?
If you do not hold a freehold interest or long lease with full repairing obligations, please answer the
following questions:
Please detail below the value of any work you can carry out without further authorisation and the
procedure which you must follow if works exceed this limit.
12
Section 4: Details of person or organisation having control of
the property
4.1
Title:
Mr Mrs Miss Ms
Other
Full name:
Residential address:
P
roof of address:
Postcode:
Driving licence
Bank statement Utility bill
Other
Contact name:
Business address:
(if applicable)
Proof of address:
Postcode:
Business rates
Utility bill
Home tel no: Mobile tel no:
Work tel no:
Fax no:
Email address:
Date of birth:
Interest in property:
Owner
Manager Leaseholder
Other
4.2
Are you the freeholder or the leaseholder?
Freeholder
Leaseholder
Neither
13
Section 1: Details of property to be licensed
To be completed for all properties requiring a licence
1.1
Please attach a sketch plan, with measurements, showing the location and size of each
room in the property. Below is an example showing the type of sketch and detail required.
Please use the abbreviations listed below to mark details on the plan. Please provide a
separate sketch of each floor level of the property. Please add additional sheets if you
require further space. If you already have plans of the property you may submit these
separately.
EW
5 m.
Final exit to street
CP
Key of symbols to be used on plan
FD
Fire door
EW
Escape window
EL
Emergency lighting
CP
Manual call point
5 m.
4 m.
Letting No.1
SD
Letting No.2
1.5 m.
SD
AS
Hall
FD
EL
FD
FAP
Fire alarm control panel
SD
Smoke detector linked to whole house
system
HD
Heat detector linked to whole house
system
4.5 m.
SD
AS
DP
5 m.
1 m.
FD
FD
4 m.
gas and
electric
meter
cupboard
AS
Alarm sounder linked to whole house
system
SA
Combined smoke detector/alarm,
may be linked or stand alone
HA
Combined heat detector/alarm,
Shared Kitchen
HD
FB
F
C
SH
Utility
WC
Room
Conservatory
S
W HB
may be linked or stand alone
FB
Fire blanket
WE
Water extinguisher
FE
Foam extinguisher
DP
Dry powder extinguisher
SH
Shower
B
Bath
WHB
Wash hand basin
C
Cooker
EXAMPLE GROUND FLOOR PLAN
S
Sink
F Fridge
Note: All fastenings to doors required for escape purposes must be thumb-turn type
locks, easily openable from the inside without the use of a key.
Part 2
–
Property details
14
Sketch Plan
Notes
15
Sketch Plan
Notes
16
Sketch Plan
Notes
17
Sketch Plan
Notes
18
Sketch Plan
Notes
19
1.2 Please indicate the type of property to be licensed:
Detached Terrace
Semi-detached End terrace
Other
please indicate:
1.3 Please give approximate date of construction of the property:
Pre 1919
1945 - 1964
Post 1980
1919 - 1944 1965 - 1979
1.4
If the whole or part of the property has been converted, for example, into self-contained flats,
what was the approximate date of conversion:
Date:
1.5 Please provide details of any building works carried out to the property. Please include copies of
planning consents, building regulations approval or certificates issued on completion of works.
Description of works
Date of completion
1.6 How many storeys are there in the property? Include basement and attic conversions but not
cellars.
1 2 3 4 5 6 7 8 9 10
1.7
Over which levels are the storeys situated, such as ground floor, first floor, second floor?
Basement First floor Third floor
Ground floor Second floor
Fourth floor
Other
please indicate:
1.8 Is any part of the property used for separate commercial activity?
Yes No
1.9
If yes, please give details and location of the commercial activity below:
2.0
How many separate letting units (eg self-contained flats or bedrooms) are there in the property?
1 2 3 4 5 6 7 8 Other
2.1
How many households occupy the property at present?
(see note 9 for 'household' definition)
2.2
What is the maximum number of households that could occupy the property?
20
2.3
Please indicate the number of households you would like the licence for.
2.4
How many individual people occupy the property at present?
2.5
What is the maximum number of people who could occupy the property?
2.6
Please indicate the number of occupants you would like the licence for.
2.7
Is there a resident landlord?
Yes No
If no, please go to question 3.0
2.8
Is the proposed licence holder the resident landlord?
Yes
No
2.9
Number of people resident in the landlord's household, excluding the landlord?
2.10
Which rooms in the property are occupied by the resident landlord's household?
3.0
What form of heating is there in the bathroom/s? (For shared properties only)
Radiator/s as part of the gas/oil fired central heating system
Yes
No
Individual wall-mounted electric heater/s
Other, please state:
3.1
What form of heating is there in the kitchen/s? (For shared properties only)
Radiator/s as part of the gas/oil fired central heating system
Yes
No
Individual wall-mounted electric heater/s
Electric storage heater/s
Other, please state:
3.2
What form of heating is there in the common parts such as hallways and stairwells?
Radiator/s as part of the gas/oil fired central heating system
Yes
No
Individual wall-mounted electric heater/s
Electric storage heater/s
Other, please state:
3.3
Are there any gas appliances in the property?
Yes No If yes, please provide a copy of a valid gas safety certificate.
21
Please complete the following table indicating the facilities that are provided within the whole
dwelling. Tick the boxes relevant to indicate the facilities that each individual letting unit has use
of within the property.
Letting unit
Facilities
1 2 3 4 5 6 7 8 9 10 Total
Number of people sharing unit
Number of bedrooms
Wash basin in property
- if shared property
Shared living room
Exclusive living room
Dining room
Shared kitchen/s
Exclusive kitchen
4-hob cooker, oven and grill
Microwave
Dedicated cooker point
Sink with drainer and base
unit
Refrigerator/s with freezer
compartment
Freezer
Shared bathroom/s with water
closet and wash hand basin
Shared shower room
- separate
Exclusive bathroom with water
closet and wash hand
bi
marleFixed heating such
as gas central heating
Electric storage heating
Other heating, non-portable
- please specify
22
Section 2: Details of facilities and management
To be completed for all properties requiring a licence
4.1
Is there a system of fire detection incorporating:
A fire alarm control panel
Yes
No
Sounders or alarms on all levels
Emergency lighting in the common hallways
Mains powered smoke/heat alarms in kitchen and common
rooms and hallways
Battery operated smoke alarms
4.2
Is there a current fire alarm test certificate in compliance with BS5839 Part
1:2002, as amended by BS5839 Part 6:2004?
If yes, you will need to attach the original test certificate
4.3
Is a contractor employed to inspect and maintain the fire alarm system?
If yes, please state the name of the company:
4.4
Is there a current emergency lighting test certificate in compliance with
BS5266 Part1:1999?
If yes, you will need to attach the original test certificate
4.5
Are the kitchen(s) and kitchen areas protected by fire doors?
If yes, are they fitted with:
Self-closers
Smoke seals
Intumescent strips
4.6
Are all the doors that open onto the main escape route 30 minute fire resistant
doors that incorporate self-closers, smoke seals and intumescent strips?
If no, which doors are not:
4.7
Are the fire extinguishers provided and tested annually?
If yes, please state type and location:
Type of extinguisher Location of extinguisher
23
Yes
No
4.8
Are fire blankets provided in the kitchen/s?
4.9
Is the escape route kept clear of flammable materials and other obstructions?
4.10
Is the main exit door openable from the inside without the use of a key?
4.11
Does the property incorporate a sprinkler system?
4.12
Has a fire safety risk assessment been undertaken at the dwelling?
If yes, please provide a copy
4.13
Is upholstered furniture provided in the property?
If yes, does it comply with the Furniture (Fire Safety) Amendment
Regulations 1993?
25
I declare the information provided in this application is true and correct to the best of my
knowledge. I understand that a criminal offence is committed if I supply any information to a
local housing authority in connection with this application for a licence of a House in Multiple
Occupation that is knowingly false or misleading and on conviction may be fined up to £5,000.
NOTE: If you are the applicant AND the proposed licence holder or manager you must sign all
the relevant sections below.
Applicant
Name:
(please print)
Signature:
Date:
Proposed licence holder
Name:
(please print)
Signature: Date:
Manager or managing agent
Name:
(please print)
Signature: Date:
Person having control of
the property
Name:
(please print)
Signature:
Date:
Enclosures
(as appropriate)
a. Evidence of permanent residential address of proposed licence holder
b. Building regulations completion certificate and planning consents, if applicable
c. Current fire alarm test certificate
d. Current emergency lighting test certificate
e.
Service contract for alarm and safety systems
f. Current landlord's Gas Safety Certificate
g.
Most recent periodic test certificate for the electrical installation
h.
Most recent PAT (Portable Appliance Testing) certificate, if applicable
i. Fire safety risk assessment, if applicable
j.
Licensing fee – see www.rochdale.gov.uk for more details.
Declaration of applicant and proposed licence holder
Please note it is a criminal offence to knowingly supply information that is false or
misleading for the purposes of obtaining a licence. Evidence of any statements made in this
application may be required at a later date. If we subsequently discover something that is
relevant and that you should have disclosed, or which has been incorrectly stated or described,
your licence may be cancelled or other action taken. Operating a HMO that should be licensed
without a licence is an offence liable to a fine not exceeding £20,000. In addition, a Residential
Property Tribunal may make a rent repayment order requiring you to repay any rents due during
the period for which the property was unlicensed.
Part 3 - Declarations
26
Declaration of applicant and proposed licence holder
You must let certain people know in writing that you have made this application, or give them a
copy of it, as follows:
•
Any mortgagee of the property.
•
Any owner of the property to which this application relates, if that is not you, such as the freeholder,
and any head lessees who are known to you.
•
Any other person who is a tenant or leaseholder of the property or any part of it, including any flat,
who is known to you, other than a statutory tenant or other tenant whose lease or tenancy is of less
than three years, including a periodic tenancy.
•
The proposed licence holder, if that is not you.
•
The proposed managing agent, if any, if that is not you.
•
Any person who has agreed that he or she will be bound by any condition or conditions in a licence,
if it is granted.
You must tell each of these people:
•
Your name, address, telephone number and email address.
•
The name, address, telephone number and email address of the proposed licence holder, if it
will not be you.
•
That this is an application under Part 2 (Houses in Multiple Occupation) of the Housing Act 2004).
•
The address of the property it relates to.
•
The name and address of the local authority to which the application will be made.
•
The date the application will be submitted.
I confirm I have served notice of this application on the following people, who are the only
people known to me that are required to be informed that I have made this application.
Name:
(please print)
Signature: Date:
Name:
(please print)
Signature: Date:
Name:
Address:
Postcode:
Email address:
Interest in the property
or the application:
Date of service of notice:
27
Name:
Address:
Postcode:
Email address:
Interest in the property
or the application:
Date of service of notice:
Name:
Address:
Postcode:
Email address:
Interest in the property
or the application:
Date of service of notice:
Name:
Address:
Postcode:
Email address:
Interest in the property
or the application:
Date of service of notice:
Name:
Address:
Postcode:
Email address:
Interest in the property
or the application:
Date of service of notice:
28
The following information is discretionary and you do not need to answer the questions. However,
if you do answer the questions it will assist the local authority in assessing their housing stock.
Ethnicity
of the
proposed
licence
holder
Asian/Asian British
Indian
Pakistani Bangladeshi Other Asian
Black/Black British
Caribbean Black Other Black background
Chinese or other
ethnic group
Chinese Any other ethnic group - please write in:
Dual heritage
White and
Black
Caribbean
White and Black
African
White and
Asian
Other dual
heritage
background
White
British Irish Other
How old is the bathroom?
How old is the kitchen?
Is there adequate noise insulation between the converted flats?
Yes
No
Does the property have cavity wall insulation?
Yes
No
Does the property have loft insulation?
Yes
No
If yes, what thickness is the insulation?
January 2018
V1
End
Find out how we us
e your personal information at rochdale.gov.uk/privacy.
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Form 1: Application for variation of HMO (Houses (Rochdale Metropolitan Borough Council)

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Completed 10 December 2020

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