Fillable Rental Dwelling License Application$125 License Fee Page 1 (City of Golden Valley)

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Rental Dwelling License Application$125 License Fee Page 1 (City of Golden Valley)

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Rental Dwelling License Application—$125 License Fee Page 1 of 2
License Type Information
☐
New rental ☐ Renewal license ☐ Has other rental property in Golden Valley_____________
Is tenant a family member? ☐ No ☐ Yes. Please specify:______________________________________
Rental Property Information
Rental property address
Type of dwelling (select one)
☐ Single Family ☐ Condo/Townhome ☐ Duplex/Twinhome
Property Owner Information
Type of Ownership
☐ Individual ☐ Partnership ☐ Corporation ☐ Contract for Deed
Property owner’s name(s) Business name (if applicable)
Property owner’s street address ZIP
Home phone Cell phone Work phone
Email(s)
Rental Dwelling Agent (Required)
If owner does NOT live in Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, Sherburne, Washington or Wright County, a dwelling agent,
who resides within these counties, shall be designated by the owner to be legally responsible for compliance with Golden Valley rental
ordinances.
Manager/Management Company Information
Management company Agent
Address ZIP
Company phone Agent phone
Email
Emergency Information
Provide in case owner or management cannot be reached.
Fire Department | 7700 Golden Valley Road, Golden Valley, MN 55427-4588
763-593-8055 | FAX: 763-593-8098 | TTY: 763-593-3968 | www.goldenvalleymn.gov
u continued
Sta Use Only
Utilities owed to City?
☐ No ☐ Ye s
Date received ______________________________________
Crime Free Certificate ___________________________________________
Name Phone
Tenant inquiries & complaints to be processed through:
☐ Owner ☐ Agent
License renewal/City mailings to go to:
☐ Owner ☐ Agent
Data Practices Advisory
The City of Golden Valley will use the data you supply in this application to assess your qualifications for a license and will become
public data under the Minnesota Government Data Practices Act when received by the City of Golden Valley. This data is not legally
required, but the City will not be able to grant the license without it. The City needs this data to distinguish this application from others,
to identify this application in City license files, to verify the identity of the applicant, to contact the applicant if additional information is
required, and to determine if the applicant meets all ordinance requirements.
Per Golden Valley City Code, Section 2-3, all licenses will not be issued/renewed until all fees, charges, taxes, special assessments, and
other debts or obligations that are due from the applicant are paid in full. This means the City of Golden Valley water and sewer utility
bill also needs to be paid in full before licenses are renewed; no amount can be certified.
Every Licensee shall promptly notify the Fire Inspector (763-593-8057) of any changes in the names, addresses and other information
concertning the person(s) listed on the application within 5 days of the change. This license is NOT transferrable to another person or
to another rental dwelling unit.
In the act of filing this application with the City of Golden Valley, the owner or agent of the rental dwelling unit(s) agrees to permit
inspections. The minimum standard to be used for inspections can be found in City Code Chapter 16, Art. III.
All tenant leases must contain crime free multi-housing or equivalent language as found in the city rental housing ordinance.
All property owners must conduct a criminal background check and a criminal and civil court records check on all prospective tenants
and maintain a current register of tenants. This information must be available for review by the City upon request.
Property owners or managers who own or operate more than on rental unit: Mandatory Crime Free Multi-Housing (CFMH) training is
required and must be completed within one year of the issuance of a new rental housing license. A copy of CFMH Certificate must be
included with license application.
Department of Revenue Information form MUST be included with application for ALL NEW Rental Licenses.
Signature
The undersigned acknowledges that this application has been read and that the information provided on this application is accurate and
agrees to comply with all the ordinances and laws of the City of Golden Valley rental dwelling code.
Signature of owner
X
Print name Date
Signature of agent (if applicable)
X
Print name Date
Rental Dwelling License Application Page 2 of 2
1/21/20
Make check payable to City of Golden Valley and mail to:
Golden Valley Fire Department
Attn: Jill Lund
7800 Golden Valley Rd
Golden Valley, MN 55427
This document is available in alternate formats upon a 72-hour request. Please call 763-593-8006 (TTY: 763-593-3968)
to make a request. Examples of alternate formats may include large print, electronic, Braille, audiocassette, etc.
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Tax Identification Form
License Applicant:
Pursuant to *Minnesota Statue 270C.72 Tax Clearance: Issueance of Licenses, the licensing authority is required to provide the Min-
nesota Commissioner of Revenue your Minnesota business tax identifcation number and the Social Security number of each license
applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of
the following regarding the use of this information:
1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the Minnesota Depart-
ment of Revenue delinquent taxes, penalties or interest.
2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However, under
the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue
Service.
3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application.
Please supply the following information and return along with your application to the agency issuing the license. Do not return to the
Department Of Revenue.
Sole Proprietors ONLY
Applicant’s name
Address
City State Zip
Phone number Social Security number
Partnerships, LLCs, Corporations ONLY
Business name
Address
City State Zip
Phone number Minnesota Tax ID number Federal Tax ID number
If a Minnesota Tax ID number is not required, please explain:
DATA PRACTICES ADVISORY: In connection with your request for a license, the City has asked that you provide information about yourself which may
be classified as private, confidential, nonpublic, or protected nonpublic under the Minnesota Government Data Practices Act. This means that this data is
not ordinarily available to the general public. Accordingly, the City is required to inform you of the following:
1. The purpose and intended use of the information requested is to determine if you or an applicant aliated with you is eligible for a license from the
City of Golden Valley.
2. You are not legally obligated to supply the request information.
3. The known consequences of supplying the requested information is that the information or further investigation could disclose information which
could cause the license application to be denied.
4. The known consequences of refusing to supply the requested information is that the application for a license cannot be processed.
5. A criminal charge, arrest, or conviction will not necessarily bar you from obtaining a license with the City, unless the conviction is related to the matter
for which the license is sought, according to Minnesota Statute 364.03. However, failure to reveal the requested criminal information will be consid-
ered falsification of the application and may be used as grounds for the denial of the application.
6. Other governmental agencies necessary to process your application are authorized by law to receive the information provided.
7. The City is required by law to furnish some of this information to the Department of Labor and Industry and the Minnesota Commissioner of Revenue.
270C.72 Tax Clearance; Issuance Of Licenses. *2008 Minnesota Statutes Subd. 4. Licensing authority; duties.
All licensing authorities must require the applicant to provide the applicant’s Social Security number and Minnesota business identification number on
all license applications. Upon request of the commissioner, the licensing authority must provide the commissioner with a list of all applicants, including
the name, address, business name and address, Social Security number, and business identification number of each applicant. The commissioner may
request from a licensing authority a list of the applicants no more than once each calendar year.
Signature
X
Print Name Date
Fire Department | 7700 Golden Valley Road, Golden Valley, MN 55427-4588
763-593-8055 | FAX: 763-593-8098 | TTY: 763-593-3968 | www.goldenvalleymn.gov
1/21/2020
This document is available in alternate formats upon a 72-hour request. Please call 763-593-8006 (TTY: 763-593-3968)
to make a request. Examples of alternate formats may include large print, electronic, Braille, audiocassette, etc.
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LEASE ADDENDUM FOR CRIME-FREE/DRUG-FREE HOUSING
In consideration of the execution or renewal of a lease of the dwelling unit identified in the lease, Owner
and Resident agree as follows:
1. Resident, any members of the resident's household, or a guest or other person under the resident's
control shall not engage in illegal activity, including drug-related illegal activity, on or near the said
premises. "Drug-related illegal activity" means the illegal manufacture, sale, distribution, purchase, use,
or possession with intent to manufacture, sell, distribute, or use of a controlled substance (as defined in
Section 102 or the Controlled Substance Act [21 U.S.C. 802]) or possession of drug paraphernalia.
2. Resident, any member of the resident's household, or a guest or other person under the resident's
control shall not engage in any act intended to facilitate illegal activity, including drug-related illegal
activity, on or near the said premises.
3. Resident or members of the household will not permit the dwelling to be used for, or to facilitate,
illegal activity, including drug-related illegal activity, regardless of whether the individual engaging in
such activity is a member of the household.
4. Resident or members of the household will not engage in the manufacture, sale, or distribution of
illegal drugs at any locations, whether on or near the dwelling unit premises or otherwise.
5. Resident, any member of the resident's household, or a guest or other person under the resident's
control shall not engage in acts of violence or threats of violence, including but not limited to the
unlawful discharge of firearms, prostitution, criminal street gang activity, intimidation, or any other
breach of the rental agreement that otherwise jeopardizes the health, safety, or welfare of the landlord,
his agents, or tenants.
6. VIOLATION OF THE ABOVE PROVISIONS SHALL BE A MATERIAL VIOLATION OF THE LEASE AND GOOD
CAUSE FOR TERMINATION OF TENANCY. A single violation of any of the provisions of this added
addendum shall be deemed a serious violation and material non-compliance with the lease.
It is understood and agreed that a single violation shall be good cause for termination of the lease.
Unless otherwise provided by law, proof of violation shall not require criminal conviction but shall be by
the preponderance of the evidence.
7. In case of conflict between the provisions of this addendum and any other provisions of the lease, the
provisions of the addendum shall govern.
8. This LEASE ADDENDUM is incorporated into the lease executed or renewed this day between Owner
and Resident.
_______________________________ __________________________________
(Resident) (Resident)
_______________________________ __________________________________
(Resident) (Resident)
Date Signed: _______________________
________________________________ Date Signed: _______________________
(Owner / Management)
Resident(s) acknowledge receipt of this addendum by signature of this document
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Rental Housing Inspection Checklist-Interior
Security
☐☐ Locks on ground floor windows
☐☐ Exterior door locks (interior keyed
deadbolts are prohibited)
Doors and Windows
☐☐ Operational windows must have
screens
☐☐ Exterior doors solid core or
insulated
☐☐ All doors must be operational
☐☐ All garage doors must be
operational
Ceiling
☐☐ Water damage
☐☐ Cracks or chipping
☐☐ Acceptable general condition
Walls
☐☐ Holes in walls
☐☐ Cracks or chipping
☐☐ Water damage
Flooring
☐☐ Free of cracks/holes/rips etc
☐☐ Free of tripping hazards
Stairs
☐☐ Carpeting is secure
☐☐ Handrails on all stairways
☐☐ Must be illuminated
Tub/Shower
☐☐ Washable and water tight surface
around tub and floor
Toilet
☐☐ Free of chips and cracks
☐☐ Properly secured to floor
☐☐ Sanitary conditions
☐☐ Flushes correctly
Ventilation
☐☐ Bath fan installed and operable if
no window
Electrical
☐☐ All outlets/switches have plates
☐☐ All wires concealed
☐☐ No extension cords used with
appliances
☐☐ GFCI to code
Smoke Detector/CO Detector
☐☐ Present and functioning on every
floor and in every bedroom
☐☐ Carbon monoxide detectors
within 10 feet of every bedroom
Fire Extinguisher
☐☐ Fire extinguisher
Furnace/Air Conditioning
☐☐ Venting free of rust and fully
operational
Water Heater
☐☐ Verify relief valve
☐☐ Free of leaks
Washer/Dryer
☐☐ Gas dryer must have shut-o
valve
☐☐ Dryer must have metal ductwork
to exterior
☐☐ Washer must have water shut o
Dishwashers
☐☐ Permanently installed to code
☐☐ Clean and sanitary condition
☐☐ Seals in good working order
Sink/Wash Basin
☐☐ Free of chips and cracks
☐☐ Sink area water tight and wash-
able surface
☐☐ Hot and cold water
Stove/Range/Oven
☐☐ All burners and oven elements
operable
☐☐ Oven gasket in good condition
☐☐ Gas range must have shut o
valve
Refrigerator
☐☐ Fully operational, with secure
gaskets
Food Storage/Preparation
☐☐ Cabinet doors and drawers with
hardware
☐☐ Kitchen sanitary—no accumulated
garbage
Note:
This list includes the major items
covered in an inspection but may
not be totally inclusive of all items.
The property owner or agent is
responsible for notifying tenant at
least 24 hours before an inspection.
Permits may be required to
complete work. Contact Inspections
at 763-593-8090 for further
information.
1/22/2020
Fire Department | 7800 Golden Valley Road, Golden Valley, MN 55427
763-593-8055 | FAX: 763-593-8109 | TTY: 763-593-3968 | www.goldenvalleymn.gov
This document is available in alternate formats upon a 72-hour request. Please call 763-593-8006 (TTY:
763-593-3968) to make a request. Examples of alternate formats may include large print, electronic,
Braille, audiocassette, etc.
Rental Housing Inspection Checklist-Exterior
Yard Maintenance
☐☐ Trees and shrubs trimmed and
maintained
☐☐ Grass trimmed to less than eight
inches high
Driveways and Parking
☐☐ General condition
☐☐ All vehicles must be parked on
hard surface
☐☐ All vehicles must have current
tabs and be operational
Accessory Building(s)
☐☐ General condition
☐☐ Location
Refuse Storage
☐☐ Approved covered containers
☐☐ Containers not visible from street
Fences/Retaining Walls
☐☐ General condition
Building Exterior
☐☐ Roof
☐☐ Siding
☐☐ Windows
☐☐ Doors
☐☐ Foundation
☐☐ Chimneys/vents
☐☐ House numbers
☐☐ Gutters/downspouts
☐☐ Fascia/sots
Decks/Patios
☐☐ Decks 30 inches or higher have
guardrails
☐☐ Decks with three or more steps
have handrails
☐☐ Handrails and guardrails are
secure
Note:
This list includes the major items
covered in an inspection but may
not be totally inclusive of all items.
The property owner or agent is
responsible for notifying tenant at
least 24 hours before an inspection.
Permits may be required to
complete work. Contact Inspections
at 763-593-8090 for further
information.
1/22/2020
Fire Department | 7800 Golden Valley Road, Golden Valley, MN 55427
763-593-8055 | FAX: 763-593-8109 | TTY: 763-593-3968 | www.goldenvalleymn.gov
This document is available in alternate formats upon a 72-hour request. Please call 763-593-8006 (TTY:
763-593-3968) to make a request. Examples of alternate formats may include large print, electronic,
Braille, audiocassette, etc.
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Rental Dwelling License Application$125 License Fee Page 1 (City of Golden Valley)

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Completed 3 August 2020

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