Smoke Detector Self Inspection Confirmation

2. Property Owner Name*

3. Last Name*

5. Property Owner Address*

7. Property Owner Email

8. Property Owner Phone Number*

10. Please check your preference for future smoke detector notifications from the City. *

    1. Mail

    1. Email
12. Agent/Manager Name

    Name of authorized Agent/Manager who performed inspection if different than owner.

14. Street Number*

    Rental Property Address

15. Street Name*

16. Apt #

17. Date of Inspection*
    Date of Inspection

19. Street Number

    Use for additional properties

20. Street Name

21. Apt #

22. Date of Inspection
    Date of Inspection

    Required

24. Street Number

    Use for additional properties

25. Street Name

26. Apt #

27. Date of Inspection
    Date of Inspection

    Required

29. Street Number

    Use for additional properties

30. Street Name

31. Apt #

32. Date of Inspection
    Date of Inspection

    Required

34. Street Number

    Use for additional properties

35. Street Name

36. Apt #

37. Date of Inspection
    Date of Inspection

    Required

39. Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you have inspected all smoke detectors located at the above address(es) and that at the time of the inspection, all smoke detectors required by the City of Storm Lake housing code were properly installed and in good working order.

    1. I Agree
41. Electronic Signature*

42. Signer is:
    -- Select One --OwnerManagerTenant

44. rentals@stormlake.org~712-732-8002

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

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