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Housing Inspection Application
Board of Health Use                             Fee paid:                                       Check # ________                
 BOARD OF HEALTH, 250 Main Street, Rutland, MA 01543                              508-886-4102
               {11943940-36DE-11CF-953E-00C0A84029E9}9272016_121936_0.png                                      HOUSING INSPECTION APPLICATION                                                                                                    Fee:    $65.00            
Address of property to be inspected______________________________________

Applicant(s): (Person requesting Inspection)__________________________________________
Applicant’s address (if different than property to be inspected):____________________________
Applicant’s telephone no.(s)________________________________________________________

Property owner’s address:__________________________________________________________
Property owner’s telephone no.(s)___________________________________________________                         

Complaints by Applicant(s)
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
  • _________________________________________________________________________
Residents living at property being inspected:    
Name                            Age                             List any disabilities
  • _________________________________________________________________________________________
2.   _________________________________________________________________________________________
3.   _________________________________________________________________________________________
4.   _________________________________________________________________________________________
5.   _________________________________________________________________________________________
6.   _________________________________________________________________________________________
*Date and time of inspection:___________________________________________________________________
       (*Owner and applicant are required to be in attendance during the inspection. This is  
           the responsibility of the applicant.)
*Applicant’s Signature ________________________Date ____________________________

*Owner’s Signature____________________________Date ___________________________

Please call the Board of Health Agent, Randy Mizereck @ 978-928-5160 for inspection. Health Agent/Board of Health will schedule the date and time of inspection. This fee covers one inspection.  Reinspections and rescheduling without 48 hours notice will require forfeiture and or additional fees as required.  

INSPECTION REPORT ON REVERSE SIDE TO BE COMPLETED BY INSPECTOR.   →→→→→→→→


******************* TO BE COMPLETED BY THE BOARD OF HEALTH AGENT*****************

                                HOUSING INSPECTION REPORT


Property Address _________________________________________________________

Owner of Property_________________________________________________________
Owner’s Address   _________________________________________________________
Phone No._________________________________________________________________

Applicant Requesting Inspection_____________________________________________    
Applicant’s Address(if different than property being inspected) __________________________________________________________________________
Phone No. _________________________________________________________________

Date & Time of Inspection ____________________________________________________
Inspection conducted by:______________________________________________________
Owner & applicant present for inspection?:                         yes                            no

********************************************************************************************
Findings of Inspection:  
   
Repairs/replacements of the following problems must be made by the property owner within:
______________30 days   _______________15 days    ________________7 days _____________immediately

1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
6.__________________________________________________________________________________________
7.__________________________________________________________________________________________
8.__________________________________________________________________________________________
9.__________________________________________________________________________________________
10._________________________________________________________________________________________
11._________________________________________________________________________________________
12._________________________________________________________________________________________
13. _________________________________________________________________________________________
14. _________________________________________________________________________________________



Additional inspection report attached.                    Yes                       No

Date copies of report were sent to Applicant and Owner______________________________

cc: Town Departments/Boards: _________________________________________________



 
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