2. Type of Registration*

   1. Initial Registration
   2. 6 Month Renewal
   3. Late Fee
3. Parcel ID # (if known)
4. Type of Structure*
   -- Select One --Residential (1-2 Units)Residential (3+ Units)Commercial, Manufacturing, Storage or any Non-residential
6. Legal Address of Vacant Property*
8. 24-Hour Emergency Contact Number*
   ex: (612) 555-1234
9. Contact First Name
10. Contact Last Name
12. Owner's First Name*
13. Owner's Last Name*
14. Owner's Phone*
16. Owner's Mailing Address*
17. Owner's City*
19. State*
20. Zip Code*
21. Owner's Email Address
23. Name of Person(s) Authorized to be present in the structure per Section 18-454(6)
25. First Name
26. Last Name
27. Phone Number
29. First Name
30. Last Name
31. Phone Number
33. Insurance Company Name
34. Insurance Company Mailing Address
36. City
37. State
38. Zip Code
40. 24 hour contact for Insurance Co
41. Contact Email
43. Proof of Insurance Attached Sec 18-457 Required Liability Insurance

    1. Attached
    2. Will email to vacantproperty@cityofedwardsville.com
44. Proof of Insurance Upload
    Attach scanned pdf document.
46. Type of Structure
    Minimum Liability Insurance Amount: Residential properties of one or two units $250,000.00; Residential Properties of three or more units $500,000.00; Commercial, manufacturing, storage or any nonresidential property $1,000,000.00
48. Expected date of vacancy (including the date of initial vacancy)*
50. Plan including timeline for regular maintenance during vacancy*
52. Plan and timeline for lawful occupancy rehabilitation, removal, or demolition of the structure*
54. Measures/plans (including timeline) to ensure structure will be secure*
56. Timeline of structure to be free of nuisance conditions.*
58. City Utility Bills: Section 118-98(a) of the City's Codified Ordinances states that the occupant shall be primarily responsible for payment for utility service (water, sewer, and trash) at such premises; however, the owner of the premises shall be responsible for payment for the service if the occupant fails to pay. Such service is furnished to the premises by the city only upon the condition that the occupant of the premises shall be liable therefore to the city. I certify that I am aware of the City’s Building Safety codes and Zoning (occupancy) codes and the legal ramifications for knowingly violating said codes. I acknowledge that I am responsible for delinquent utility bills due to the City of Edwardsville for the property.
60. Owner's Signature (required to process the form)*
61. Owner's Agent Signature (Electronic Signature)
63. Vacant Registration Fee
    6 month Registration Fee
64. Price
65. 6 month period
67. Late Registration Fee
    Late Registration Fee
68. Price
69. Quantity

    Registration received after (6) month period.

71. Shipping Cost
72. Taxable
73. Shipping Cost
74. Taxable
Leave This Blank:


75. Calculate Totals Proceed to Checkout

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