OFFICE USE ONLY
Application No.
Application Submittal Date
Accepted By
Community & Economic
Development Department
520 J St.
Los Banos, CA 93635
Phone: (209) 827-7000 ext. 2432
www.losbanos.org
Rev. 11/6/2020
VACANT AND BOARDED BUILDING REGISTRATION FORM
PROPERTY TYPE: (Check One) Commercial $312.86 Residential $312.86
PROPERTY OWNER INFORMATION (IF MORE THAN ONE OWNER, LIST ON SEPARATE SHEET OF PAPER):
Full Name
Last Name
Mailing Address City/State/Zip
Cell Phone ( ) Other
Phone
( )
Email Address
Property Owner’s Signature _______________________________________________ Date ______________________ _______ PROPERTY OWNER’S AFFIDAVIT: I hereby certify under penalty of law that I am the owner of the above-referenced property.
PROPERTY MANAGEMENT INFORMATION:
Company Name
Contact Person
Mailing Address City/State/Zip
Cell Phone ( ) Other
Phone
( )
Email Address
Complete this form, make check payable to the “City of Los Banos”, and mail to:
City of Los Banos
Community & Economic Development Department
520 J Street
Los Banos CA, 93635
The fee and registration is valid for one (1) year from the date of the registration and is due annually as long as property is vacant. You are required to renew your registration every year that your property is vacant. Please note, the fees may be subject to annual increases. If you have any questions, contact Associate Planner, Rudy Luquin at (209) 827-2432.
____________________________________ __________________________________ _______________________ Property Owner’s Signature Print Name Date
____________________________________ __________________________________ _______________________ Property Management’s Signature Print Name Date
Rev. 11/6/2020
OFFICE USE ONLY
Los Banos Fire Department Review
Approved Denied
Comments (Please use additional pages as necessary):
Department Reviewer: Date
Los Banos Code Enforcement Department Review
Approved Denied
Comments (Please use additional pages as necessary):
Department Reviewer: Date
Community & Economic Development Department Review
Approved Denied
Comments (Please use additional pages as necessary):
Department Reviewer: Date
Finance Department Review
Approved Denied
Comments (Please use additional pages as necessary):
Department Reviewer: Date