Application for Licence House in Multiple Occupation (HMO)

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1 Application for Licence House in Multiple Occupation (HMO) Please use the accompanying notes when completing this form. If you have more than one house in multiple occupation you will need to complete a separate application form for each property. Please fill in the form using BLOCK CAPITALS and black ink. If you require more space to answer any question, please use additional sheets, specifying which question your answer relates to, and attach the sheets to the application form. For Office Use Only Date Received Reference Number Fees Received Officer Type of application: New Renewal Address of property to be licensed Description of occupation (please tick appropriate boxes) Bedsits with shared facilities Bed & Breakfast Postcode: Mixture of self contained units and bedsits A house converted into self contained flats (Studios) Other (please specify) PART 1. APPLICANT DETAILS (see note 1) Telephone Numbers Home: Work: Date of Birth: Mobile:

2 PART 2. PROPOSED LICENCE HOLDER DETAILS (see note 2) 2.1 Details of proposed licence holder (if a company, please give full company name) (Individual or Company) (if company please give registered office address) Address for correspondence with company (if different to registered office address) Telephone Numbers Home: Work: Date of Birth: Mobile: Name of company secretary (if applicable) Name of directors/partners/trustees: (if applicable) Full Names: 2.2 Is the proposed licence holder a member of any landlords' association, accreditation scheme or other professional body? Yes Please specify No PART 3. MANAGER DETAILS (see note 3) 3.1 Has an agent or individual been employed to manage the property? Yes No 3.2 Details of manager (if a company, please give full company name) (Individual or Company) Page 2

3 (if company please give registered office address) Address for correspondence with company (if different to registered office address) Telephone Numbers Home: Work: Date of Birth: Mobile: Name of company secretary (if applicable) Name of directors/partners/trustees: (if applicable) Full Names: 3.3 Is the manager a member of a regulatory body/accreditation scheme or professional association? Yes Please specify No PART 4. OWNERSHIP AND CONTROL OF THE PROPERTY TO BE LICENSED (see note 4) 4.1 Name of Freeholder(s). Please continue on an additional sheet if necessary Name of Freeholder 1 (if a company, please give full company name) (if company please give registered office address) Telephone Number: Name of Freeholder 2 (if a company, please give full company name) Page 3

4 (if company please give registered office address) Telephone Number: Name of Leaseholder (if a company, please give full company name) (if company please give registered office address) Telephone Number: 4.2 Name of Mortgagee (if applicable or if none, state none) e.g. bank, building society or other who has a loan secured against the property (registered office address) Telephone Number: 4.3 Name of any other person who may be bound by a condition of the proposed licence and not referred to in parts 1,2 or 3 of the form (if none, state none) (if company please give registered office address) Telephone Number: PART 5. FIRE SAFETY (see note 5) 5.1 Has a fire risk assessment of the property been undertaken Yes No 5.2 Are the fire precautions equipment serviced and inspected by a Yes No competent person at regular intervals? Page 4

5 PART 6. PROPERTY MANAGEMENT (see note 6) 6.1 Is there, displayed in a suitable position within the property, Yes No a notice giving the name and telephone number of the manager? 6.2 Is there a maintenance programme in place? Yes No 6.3 Is there a cleaning programme in place? Yes No PART 7. TENANCY MANAGEMENT (see note 7) 7.1 Are occupants given a tenancy agreement Yes No (or other written statement of terms of occupancy) 7.2 Does the written statement of terms include any clauses relating to Yes No anti-social behavior 7.3 Does the written statement of terms include guidelines on Yes No procedures for occupants to report necessary repairs and make complaints about the property? 7.4 Are the occupants given an emergency 24 hour contact telephone Yes No number in relation to the property? If yes, please provide the number 7.5 Is the proposed licence holder or manager a member of any Yes No government authorised scheme that protects tenants' deposits? If your HMO consists entirely of self-contained flats, please compete PART 8B only. PART 8A. Occupier Information (see note 8A) (for house comprising bedsits with shared facilities OR a mixture of bedsits & Studios) Location to be taken when looking at the property from the front at street level Room name Description e.g. bedsit, living room occupiers Households e.g. Ground Floor Front Right room Room 4 Bedsit Page 5

6 Location to be taken when looking at the property from the front at street level Room name Description e.g. bedsit, living room occupiers Households Please continue on separate sheet if necessary. If you have completed PART 8A, please go straight to PART 9. PART 8B. Occupier Information (see note 8B) (for houses comprising entirely of self-contained flats) Location to be taken when looking at the property from the front at street level Flat name e.g., Flat 2, etc Comprising e.g., living room, bedroom occupiers Households e.g. Ground Floor Front Right room Flat 1 Living Room Bedroom 1 Bedroom Please continue on separate sheet if necessary. Page 6

7 PART 9. RELEVANT INFORMATION (see note 9) 9.1 Subject to the provisions of the Rehabilitation of Offenders Act 1974, please state the particulars of any relevant issues (see below) recorded against any person named in Parts 1, 2, 3 and/or 4 or any person associated or formerly associated on a personal or work basis with those named in Parts 1,2,3 or 4. If not applicable please write 'NONE'. NAME DATE COURT OFFENCE SENTENCE Please continue on separate sheet if necessary. Relevant issues include: i. Criminal offences involving: Fraud, Dishonesty, Violence, Drugs, Schedule 3 of the Sexual Offences Act 2003 ii. Practiced unlawful discrimination on grounds of sex, colour, race ethnic or national origins or disability in connection with a business. iii. Contravened any provision of housing and/or landlord and tenant law. These include but are not limited to: a. A Control Order under the Housing Act 1985 b. Proceedings by a local authority c. A Management Order under the Housing Act 2004 d. Harassment or illegal eviction v. Contravened any Approved Code of Practice (AcoP) vi. Any criminal offence or subject to any other proceedings brought by a local authority or other Regulatory Body (for example breaches of the Environmental Protection Act 1990, planning control or compulsory purchase proceedings or fire safety requirement(s) 9.2 Has any person named in Parts 1,2,3 and/or 4 of this form previously held or do they currently hold a license for another house in multiple occupation? Yes No If yes, please provide the addresses of these properties and details of the Authorities that issued the license. HMO Address Name of Local Authority Page 7

8 9.3 Has any person named in Parts 1,2,3 and/or 4 of this form ever Yes No applied for and been refused a license for a house in multiple occupation? If yes, which Authority refused the licence? When was it refused? PART 10. ADDITIONAL INFORMATION (see note 10) I/we declare that I/we have served a notice of this application on the following persons who are the only persons known to me/us that are required to be informed that I/we have made this application. Name Address Date of service Description of the persons interest in the property or application Please continue on separate sheet if necessary. Note to applicants: It is a criminal offence to knowingly supply information which is false or misleadingly for the purposes of obtaining a licence. Evidence of any statements made in this application with regard to this property maybe required at a later date. We may approach other departments in the Council or other authorities such as the Police, Fire and Rescue Service, Office of Fair Trading etc. and tenants for additional information and verification. Signing of this application will be taken as your agreement to any such action. If we subsequently discover something which is relevant and which you should have disclosed, or which has been incorrectly stated or described, your licence may be cancelled or further action taken. PART 11. DECLARATION (see note 11) If this is a new application please tick box below. 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 am/are reckless as to whether it is false or misleading. Page 8

9 If this is a renewal and please tick appropriate box I/We declare that the house in respect of which a licence is sought under Part2/Part 3 of the Housing Act 2004 is subject to a licence under that Part at the time this application is made. I/We further declare that to the best of my/our knowledge either: (a) none of the information described in paragraph 2(c) to (g) of that Act and previously submitted to the authority has materially changed since that licence was granted; or (b) the only material changes to that information are described as follows: [include description of all material changes]. Name of applicant Signature Date Name of proposed licence holder (If different to applicant) Signature Date PART 12. REQUIRED DOCUMENTATION (see note 12) Please note your licence will not be processed unless we have received all the documentation below: Renewals where there has been no material change: An Electrical Installation Condition Report including a schedule of inspections along with the test results in accordance with BS7671 (IEE Wiring Regulations). Gas safety Certificate from a Gas Safe Registered approved gas engineer Tenancy agreements for all tenants in the property Page 9

10 Current test certificate for the fire alarm system Current test certificate for emergency lighting (if present) Cheque made payable to London Borough of Hounslow New Applications or where there has been a material change to your property : All the above and A sketch plan of your property. Please use the key provided in the sample plan to show the following details; a) every habitable room on every floor of the house (i.e. living room, dining room, kitchen and bedroom) b) all the facilities and amenities in your property (i.e. bathrooms, shower rooms, toilets, wash hand basins and sinks) c) dimensions of every room (to be specified in m 2 ) The Council may require you submit, or you may wish to submit other documents to support your application. Please note the information you have supplied will be used in the Public Register for Licensed Houses in Multiple Occupation. Please return your completed application form, payment and all documentation to: HMO Licensing Private Sector Housing Civic Centre Lampton Road Hounslow TW3 4DN Should you have any queries, the HMO Licensing Team can be contacted on: Telephone: Page 10

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