Form WH-520 Housing Occupancy Certificate--Migrant and Seasonal Agri

Housing Occupancy Certificate — Migrant
and Seasonal Agricultural Worker
Protection Act

U.S. Department of Labor
Employment Standards Administration
Wage and Hour Division

NOTE: Persons are not required to respond to this collection of information unless it displays a currently
valid OMB control number.

OMB Number: 1215-0158
Expiration Date: 06-30-2008

A. IDENTIFYING INFORMATION
1. Location of Housing Inspected:

Description of Housing Units and Number of Units:

2a. Name and Address of Owner of Housing Units:

3a. Name and Address of Individual(s) in Charge:

b. Phone:

b. Phone:

4a. Name and Address of Farm Labor Contractor, if Any:

5. Date Inspection was Requested:

6. Expected Dates of Occupancy
From:
To:

b. Registration No.:

B. CERTIFICATION: For Completion By Agency Personnel Conducting Housing Inspection
The housing identified above has been inspected by the undersigned and found to
meet the substantive safety and health standards prescribed in one of the following
Department of Labor regulations.
29 CFR 1910.142 Occupational Safety and Health Administration Regulations
20 CFR Part 654 Employment and Training Administration Regulations

Date of Inspection:
Date Certificate Expires:
Maximum Occupancy:

The definition of substantive safety and health standards is given in 29 CFR 500.133.
Special Conditions (If none, write “None”):

District Office Address:

(Signature and Title of Person Issuing Certificate)

(Date Issued)

Important Notice: A copy of this certificate must be posted at the site of the housing identified above. This certificate is valid for one year from the date
of issuance. If after one year from the date of this certificate the property identified above is to be utilized to house migrant workers, a new certificate must
be requested.
The original of this certificate must be kept as a record for three years from the date of issuance.
This inspection certificate does not relieve any person from compliance with any applicable State, county or local ordinance. Receipt and posting of this
certificate of occupancy does not relieve the persons who own or control this facility or property from the responsibility of ensuring that such facility or
property meets the applicable State and Federal safety and health standards. Once such facility or property is occupied, such person shall supervise
and continually maintain such facility or property to ensure that it remains in compliance with the applicable safety and health standards.

Public Burden Statement
Public reporting burden for this collection of information is estimated to average 4 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department
of Labor, Administrator, Wage and Hour Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.
Form WH-520
Rev. November 2007