Modified 3/20/2017
UNDER SECTION 107.6 OF IPMC IT SHALL BE UNLAWFUL FOR THE OWNER OF ANY DWELLING UNIT OR
STRUCTURE WHO HAS RECEIVED A COMPLIANCE ORDER OR UPON WHOM A NOTICE OF VIOLATION HAS
BEEN SERVED TO SELL, TRANSFER, MORTGAGE, LEASE OR OTHERWISE DISPOSE OF SUCH DWELLING UNIT
OR STRUCTURE TO ANOTHER UNTIL PROVISIONS OF THE COMPLIANCE ORDER OR NOTICE OF VIOLATION
HAVE BEEN COMPLIED WITH, OR UNTIL SUCH OWNER SHALL FIRST FURNISH THE GRANTEE, TRANSFEREE,
MORTGAGEE OR LESSEE A TRUE COPY OF ANY COMPLIANCE ORDER OR NOTICE OF VILOATION ISSUED
BY THE CODE OFFICIAL AND SHALL FURNISH TO THE CODE OFFICIAL A SIGNED AND NOTARIZED
STATEMENT FROM THE GRANTEE, TRANSFEREE, MORTGAGEE OR LESSEE, ACKNOWLEDGING THE RECEIPT
OF SUCH COMPLIANCE ORDER OR NOTICE OF VIOLATION AND ACCEPTING THE FULL RESPONSIBILITY
WITHOUT CONDITION FOR MAKING THE CORRECTIONS OR REPAIRS REQUIRED BY SUCH COMPLIANCE
ORDER OR NOTICE OF VIOLATION.
Please print clearly. Illegible and incomplete forms will not be accepted. Please remit payment
with this application. For Corporations, a form of identification of an authorized officer of the
company, or copy of a written agreement of the corporation’s registered agent is required.
The undersigned hereby represents that, to the best of his/her knowledge, belief that all
information listed above is true, correct, and complete; and that all attachments contain the
required information.
Applicant Signature
Print Name: ___________________________________________
Signature: ____________________________________________ Date: ______________
For Office Use Only
Permit Number __________
Fee Paid $ ______________
Approved By: __________________________________________ Date: __________
Title: _________________________________________________
