1
Housing
Act 2004, Part 2
House in Multiple Occupation (HMO) Licence Application
This downloaded pdf application form can
be typed, saved and uploaded via the payment form
along with supporting documentation and online payment of fees, or printed and filled in by
hand and sent by post, or by email to
PrivateSectorHousing@southend.gov.uk.
For queries regarding the licence or assistance completing this application form please
contact PrivateSectorHousing@southend.gov.uk by email or telephone 01702 534559.
Property Address
Postcode
Is this licence: New Renewal
SECTION 1:
OWNERSHIP AND MANAGEMENT (Compulsory section)
PROPOSED LICENCE HOLDER DETAILS
Title Licensee
full name
Company name
Licensee’s address
Telephone number(s)
Email address
Postcode Date of Birth
Are you as the proposed licence holder going
to manage the property?
Yes – (Mana
ger details section does not require
completion)
No
Specify all address(es) below of all other rented properties owned by the licence holder within
Southend-on-Sea
Address Post code
2
Specify any address(es) below of rented properties owned by the licence holder outside of Southend-
on-Sea
Address Post code
Please list below any landlord accreditation schemes the licensee is a member of membership
number
MAN
AGER DETAILS
N.B. If the Manager is a company, please enter its registered address below
Is there a Manager for the property?
Yes
No - skip to Owner/Freeholders details
Title Manager’s
full name
Company name
Manager’s address
Telephone number(s)
Email address
Postcode Date of Birth
Please list below any landlord accreditation schemes the Manager is a member of membership
number
3
Please list below other relevant property management experience or training.
OW
NER/FREEHOLDER DETAILS
Please provide the owners/ freeholder’s details. If the freeholder is a company, please enter its
registered address below.
Title Freeholder’s
full name
Company name
Freeholder’s address
Telephone number(s)
Email address
Postcode Date of Birth
Specify all address(es) below of all other rented properties owned by freeholder within Southend-on-
Sea
Address Post code
Specify any address(es) below of rented properties owned by the freeholder outside of Southend-on-
Sea
Address Post code
4
Is there a Mortgage or any other charges placed on
the Freehold?
Yes- please provide details below
No - skip to Leaseholders details details
Name related to the charge
Company name
Company address
Please briefly describe the nature of the charge e.g. mortgage, Council charge for outstanding notice
etc.
LEASEHOLDER DETAILS
Please complete the leaseholder’s details. If the leaseholder is a company, please enter its registered
address below.
Is there a leasehold within the property?
Yes
No - skip to other relevant persons
Title Full name
Company name
Address
Postcode
Tel number(s)
Email address
Date of birth
Please describe the leased premises below e.g. Flat 4 located first floor rear right.
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Is there a Mortgage or any other charges placed on
the Leasehold?
Yes- please provide details below
No - skip to other relevant persons details
Name related to the charge
Company name
Company address
Please briefly describe the nature of the charge e.g. mortgage, Council charge for outstanding notice
etc.
OTHER RELEVANT PERSONS’ DETAILS
The proposed licence holder/applicant must list the details of any other persons who have an interest
management of the property other than those whose details have been entered above and specify the
nature of their involvement:
Title Full name
Company name
Address
Postcode
Tel number(s)
Email Address
Date of birth
What is this person’s involvement in the management of your property?
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Title Full name
Company name
Address
Postcode
Tel number(s)
Email Address
Date of birth
What is this person’s involvement in the management of your property?
7
SECTION 2: GENERAL PREMISES DETAILS (Compulsory section)
How many households are currently in the property?
How many people currently live in the property?
How many households are you applying for on your licence?
How many people are you applying for on your licence?
Has the property been changed or altered in anyway since the last
licence application?
Yes
No - skip to question 2A, B
or C
What is the age of Premises?
Pre 1919
1919-1945
1945-64
1965-80
Post 1980
What type of building is it?
Detached
House
Semi
Detached
House
Terraced
House
Flat in multiple
Occupation
Residential
Block
Mixed
commercial
and residential
block
Tick all the floors in the building:
Basement
Ground Floor
First Floor
Second Floor
Third Floor
Fourth Floor
Total number of separate self-contained lettings in the whole premises
Total Number of Bedsit Rooms sharing facilities in the premises
Total number of separate rooms that are not used for sleeping, cooking or bathing
e.g. reception/living rooms (NB: exclude combined kitchen/dining rooms from this
answer).
Is the property purpose built with its current design?
Yes No
If no, what type of premises was the conversion from?
Is the property converted with planning permission?
Yes Please state the date permission was
granted
No Please state when the property was
converted
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Depending on the type of HMO please complete the sections as follows:
A MIX OF SELF-CONTAINED & BEDSIT ROOMS/BEDROOMS IN THE
PROPERTY
2A, 2B and 2C
BEDSIT ROOMS and BEDROOMS with shared amenities ONLY IN THE
PROPERTY
2B and 2C
A FLAT IN MULTIPLE OCCUPATION
2B and 2C
2A SELF CONTAINED WITHIN PROPERTY
This section considers any self-contained within the property and whether they have facilities exclusive
for their use.
Location of flat e.g. first floor, front right
Flat number/letter/name
Type of tenancy
6 months assured short
hold tenancy
12 month assured short
hold tenancy
Monthly licence Protected tenancy
leaseholder Rolling periodic other specify:
1
st
flat 2
nd
flat 3
rd
flat 4
th
flat
Number of households within the self-contained flat
Number of habitable rooms i.e. Bedrooms + living rooms excluding
all kitchens, kitchen/diners and bathrooms
Number of bathrooms or shower rooms
Number of separate WC rooms
Name(s) and age(s) of current occupants
Flat No. Tenant name under 1 1-4 5-10 11-17 18-59 60+
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Number of wash hand basins (excluding kitchen sink)
Number of Kitchens with all required facilities under the Essex
Approved Code of Practice Standards.
Number of kitchen sinks
Is there gas fired central heating in the property? Yes
No
Are there other forms of fixed heating in the property? Yes
No
If yes, please specify the other heating in the property below:
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2B - BEDSIT ROOMS / BEDROOMS (Compulsory section)
This section considers all the bedsits/rooms within the property/flat in multiple occupation, and whether they have facilities exclusive for their use or shared with other
occupiers in other bedsits or bedrooms. (When this sheet is completed sheet 2C must also be completed if you have ticked any shared facilities).
Type of tenancy’s include but are not limited to: 6months assured short hold tenancy, 12 month assured short hold tenancy, Monthly licence, Protected tenancy,
leaseholder and Rolling periodic.
Name(s) and age(s) of current occupants
Room
No.
Size of
floor area
of room
(square
meters)
Location of the
room e.g. first
floor, front right
Tenant name under 1 1-4 5-10 11-17 18-59
60+
Type of
tenancy
Exclusive
use
bath/shower
room
(Yes/no)
Exclusive
use of toilet
(Yes/no)
Wash
hand
basin in
room
(Yes/no)
Exclusiv
e use of
kitchen
(Yes/no)
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2C SHARED FACILITIES (Compulsory section)
Shared facilities are separate bathrooms/shower rooms, kitchens and WCs which are shared by more
than 1 household. This could mean being shared by separate households living in either a bedsit or
bedroom. In this section do not include facilities used only and exclusively by 1 household; these
should already be recorded in either section 2A or 2B.
Shared kitchens:
Type of Amenity
Number provided Number of occupants sharing
Kitchen sink
Wash hand basin
Oven
Hob
Number of hob rings
Number of electrical sockets
Number of cupboards (excluding
under the kitchen sink)
Size (cm x cm) of work bench
Shared Bathrooms/Shower rooms (with or without WCs):
Amenity
Number provided Number of occupants sharing
W.C.
Wash hand basin
Shower
Bath
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SECTION 3. PROPERTY MAINTENANCE (Compulsory section)
Is there a programme of regular maintenance at
the property?
Yes No
Please specify what, when and who carries out the checks and arranges subsequent works to be
carried out.
Are there arrangements in place to deal with
emergency repairs at the property?
Yes No
Please specify what your procedure is.
Is there a 24 hour emergency contact telephone
number provided for occupiers of the property?
Yes No
Specify the number(s) and who the contact is.
Name
Phone number
GAS SAFETY
Is there gas at the property? Yes
No- skip to electrical safety
Are all gas appliances within the property
annually safety checked by a gas safe
installer/engineer in accordance with the Gas
Safety (Installation and Use) Regulations 1998?
Yes
New HMO Gas safety certificate still
to be gained.
No
If no: You are in breach of Gas Safety (Installation and Use) Regulations 1998, which is a criminal
offence. Your application cannot be accepted beyond this point without a valid Gas Safe certificate.
ELECTRICAL SAFETY
Is the Electrical Installation within the property
safe?
Yes No
If no why not?
Have all the portable electrical appliances
supplied by the landlord passed the Portable
Appliance Test (PAT)
Yes
No
I do not provide any portable appliances
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FIRE SAFETY
Do you have a written fire safety risk assessment
for the property?
Yes No
If no: It is recommended that you or a contractor draw up a fire risk assessment for your property.
Does the fire detection system include:
Yes No
A fire alarm pane
Heat detectors in the kitchens
Mains wired smoke detectors in bedrooms and or living rooms
Mains wired smoke detectors in common parts
Sounders/alarms on all levels
Is the Automatic Fire Detection system tested in accordance with
BS5839?
Does the property have a system of Emergency Lighting which is
regularly tested in accordance with BS5266?
If No: You maybe in breach of Regulatory Reform (Fire Safety) Order 2005 (FSO), which is a criminal
offence.
What fire safety equipment is provided in the property?
Yes No
Fire blankets in all kitchens
Fire extinguishers
Has all the fire safety equipment been inspected in the last 12
months?
Yes No
Do you provide upholstered furniture within lettings?
Does it all comply with the Furniture and Furnishings (Fire Safety)
Amendment Regulations 1993?
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How many fire escape routes are there in the building?
Please describe the fire escape route (tick all that applies).
Yes No
30 minute fire protected external stair case
30 minute fire protected internal stair case
First floor escape window leading immediately to a safe place
First floor emergency escape window / door leading to a supported flat
roof or balcony.
Other - detail below
Yes No
Are there any notices displayed in the property instructing the
occupants what to do in the event of a fire?
Where is it displayed?
Do you provide fire safety training to occupiers?
How often this is provided & what you do for training?
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PEST CONTROL
Yes No
Has there been any infestation of pests such as mice, rats, bed bugs
or cockroaches in the property in the last 12 months?
Do you have a regular service contract with a Pest Control contractor?
(If yes, state below)
Company name
Company address
Telephone number
Email Address
Postcode
REFUSE COLLECTION
Yes No
Is there an appropriately sized and sited refuse and recycling storage
area?
How is rubbish and recycling stored whilst awaiting collection?
Is there a refuse collection contract for the property in addition to the
regular Council refuse collection day?
(Provide details below where applicable)
Company name
Company address
Telephone number
Email Address
Postcode
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TENANCY ARRANGEMENTS
Yes No
Are occupiers provided with a checked inventory and statement of
condition of the property at beginning of their occupancy?
Are occupiers provided with a written statement of the terms of
occupation at the beginning of their occupancy?
Have you been requiring tenants to sign the Anti Social Behaviour
Tenant Declaration Form?
How do you normally/plan to deal with occupiers who cause nuisance or act in an anti-social way to
neighbours?
Are there any other matters which you think should be taken into account in considering management
arrangements at the property?
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SECTION 4: FIT AND PROPER PERSON (Compulsory section)
Have you or any person who will be involved in the management of the property been
convicted of any offence involving:
Yes No
Fraud or dishonesty
Violence
Drugs
Offences under Schedule 3 of the Sexual Offenders Act 2003
If yes please give details:
Name of offender
Date of hearing
Actual charge
Penalty imposed
Any information you wish the council to consider by way of mitigating circumstances
Have you or any person who will be involved in the management of the property been found by a
tribunal or court to have:
Practised unlawful discrimination on the grounds of sex, colour, race, ethnic or national origins or
disability in or in connection with the carrying on of any business?
YES NO
If you have answered yes please give details:
Name of offender
Date of hearing
Actual charge
Penalty imposed
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Any information you wish the council to consider by way of mitigating circumstances
Have you or any person who will be involved in the management of the property any contravention of
any enactment relating to housing, public health, environmental health or landlord and tenant law,
which led to civil or criminal proceedings resulting in a judgement being made against you?
YES NO
If you have answered yes please give details:
Name of offender
Date of hearing
Actual charge
Penalty imposed
Any information you wish the council to consider by way of mitigating circumstances
Have you or any person who will be involved in the management of the property ever: Yes No
Failed to comply with a Housing Act Notice (requiring works etc) served by the local
authority?
Had works in default carried out by the local authority on a property?
Acted in contravention of any relevant approved code of practice (i.e. a code of practice
issued by the Government relating to the management of HMOs)?
Been refused a licence for a HMO?
Breached the conditions of a HMO licence?
Been subject to a Control Order (Housing Act 1985, s379)?
Been subject to an Interim Management Order?
Been subject to a Final Management Order?
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If you have answered yes please give details:
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SECTION 5:
DECLARATIONS BY LICENCE APPLICANT(S) and PROPOSED LICENCE HOLDER
Compulsory section
Please print and complete a copy of this page, scan the
signed copy and attach with the main application.
Please note that it is a criminal offence to give false or misleading information on this application form.
1) I/we declare that the information contained in this application is correct to the best of my/our
knowledge. I/we understand that I/we commit an offence if I/we supply any information to a
Local Housing Authority in connection with any of their functions under any of Parts 1 to 4 of
the Housing Act 2004 that is false or misleading and which I/we know is false or misleading or
I/we are reckless as to whether it is false or misleading.
2) I/we declare that I/we have served a notice of this application on interested person(s) or
parties who are the only person(s) or parties known to me/us that are required to be informed
that I/we have made this application:
3) I/we hereby authorise Southend-on-Sea Borough Council to investigate my background and
criminal record for the purposes of evaluating whether I/we are suitable to be involved with the
licence and or management of the House in Multiple Occupation. I/we understand that
Southend-on-Sea Borough Council will utilise outside organisation/s to assist it in checking for
such information and this, where relevant, may affect my/our ability to hold a licence or be
involved in the management or hold other involvement in the property.
Signed:
Print name:
Position: Licence holder Owner Manager Managing Agent
Date:
Signed:
Name:
Position: Licence holder Owner Manager Managing Agent
Date:
Signed:
Name:
Position: Licence holder Owner Manager Managing Agent
Date:
Add further signatories if applicable
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