Sch 1APPLICATION FOR REGISTRATION OF ACCOMMODATION

SCHEDULE 1—APPLICATION FOR REGISTRATION OF ACCOMMODATION [clause 8.3] I/We, .............................................................................................................................................................. (Full name of Applicant/s) of ................................................................................................................................................................... ....................................................................................................................................................................... contactable by .......... ....................................................................................................................................... (Mobile phone) ....................................................................................................................................................................... (Email address) apply for the registration of premises situated (or to be situated) at ........................................................ ....................................................................................................................................................................... as accommodation to be classified as— a lodging house a short term hostel serviced apartments holiday accommodation bed and breakfast chalet a recreational campsite or other (specify) and for my name to be entered in the Register as the keeper of the accommodation DESCRIPTION OF ACCOMMODATION Number of storeys ......................... Rooms for private use Number Area Laundries/toilets/bathrooms ……………….. ……………….. Bedrooms ……………….. ……………….. Dining Rooms ……………….. ……………….. Kitchens ……………….. ……………….. Sitting Rooms ……………….. ……………….. Other (Specify) ……………….. ……………….. Rooms for lodgers Number Area Bedroom ……………….. ……………….. Dining Rooms ……………….. ……………….. Kitchens ……………….. ……………….. Sitting Rooms ……………….. ……………….. Other (Specify) ……………….. ……………….. Sanitary Conveniences for male lodgers Toilets ……………….. Urinals ……………….. Baths ……………….. Showers ……………….. Hand wash basins ……………….. Sanitary Conveniences for female lodgers Toilets ……………….. Baths ……………….. Showers ……………..… Hand wash basins ……………….. Laundry Facilities Wash troughs ……………….. Washing machines ……………….. Drying cabinets or clothes lines ………………..

7 March 2018 GOVERNMENT GAZETTE, WA 789 Additional Details— (a) Lodgers’ meals will be provided by the manager/keeper/lodgers. (b) The keeper will/will not reside continuously on the premises. (c) Name and occupation of proposed manager if keeper resides elsewhere— .......................................................................................................................................................... (d) There will be ......................... family members residing on the premises with the keeper/manager. Application fee of $......................... is attached. .................................................................................................... ............................................ (Signature of Applicant/s) (Date) ————