Board of Health Use Fee paid: Check # ________
BOARD OF HEALTH, 250 Main Street, Rutland, MA 01543 508-886-4102
 HOUSING INSPECTION APPLICATION Fee: $55.00
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)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
4. _________________________________________________________________________
5. _________________________________________________________________________
6. _________________________________________________________________________
7. _________________________________________________________________________
8. _________________________________________________________________________
9. _________________________________________________________________________
10. _________________________________________________________________________
Residents living at property being inspected:
Name Age List any disabilities
1. _________________________________________________________________________________________
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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