Housing Inspection Application
Board of Health Use                                         Fee paid:                                 Check # ________                        


  BOARD OF HEALTH, 250 Main Street, Rutland, MA 01543                              508-886-4102
                clip_image002.jpg                                      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: _________________________________________________