Inspector Signature
Occupant or Occupant’s Representative Signature
Reinspection Date Time
Written description of any violation(s) checked above
Include Area or Element, code citation and a description of the condition(s) that constitute the violation. You may
include remedies that would be an acceptable means of achieving compliance with 105 CMR 410.000.
| NOTE: “indicates that this housing inspection has revealed conditions which may endanger or materially impair the
| health, safety, and well-being of any person(s) occupying the premises
| Area/Element, Code Citation and Description of Violation Acceptable Remedies
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