Area or Type of Violation Possible Code vif Responsible Party
Element Use blank boxes for ones not listed Section(s) Violation
Observed
| Ceiling height ce
Livingroom _| Lights, outlets, ventilation Ee
and Dining | Ceiling height re
Room eee Se rn
Basement ee Ce
Watertight Ec
Lighting Ee
Water Source (circle): Public Private
Must be potable EL
es Cs Se
Responsible for paying MGL ch 186 s 22, metering ie C~—sSC“(‘CC*rCd
Hot Water Fuel Type (circle): Natural Gas Oil Electric Other Temp.: _°f_Location taken:
Quantity, pressure, 110 F min, 130 max ee ee
Heating Type (circle): Forced Hot Water Forced HotAir Steam Electric
No portable units Ec
“Habitable room and every room with toilet, shower, tub” ee
© 68F7amto 11pm, 64 F 11:01 pm to 6:59 am,
except 6/15-9/15
e 78F max in heating season/measure 5 feet wall, 5
feet floor
ee a La a
Type (circle): 110 220 Amp:
Amperage, temporary wiring, metering [sos e ae [|
Drainage, Type (circle): Public Private
Plumbing Sanitary drainage required and maintained poseSC]SC(“‘(CCdLCd
Smoke & CO | Required & operational ce
moke CO | Requlted Rope
Free of pests (rodents, skunks, cockroaches, insects) es
Structural maintenance and elimination of harborage es
Asbestos or 353, 502
Lead Paint
Seime
me SSCS
Referral: Ol Electric 1 Fire Cl Plumbing 1 Building [1 Other
This inspection report is signed and certified under the pains and penalties of perjury.
Rev. 11-4-2021 Page 2 of __