HomeMy WebLinkAboutRental Form with Floor Plan Sketch THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- _* _ — CITY/TOWN
I- - DEPARTMENT
f f f ,? -- — — ------— — — ——
• -- r« ADDRESS
"` am14 TELEPHONE -- - ------
Address_ /a-64-7L1!/Ay! S. ,' Occupant —_ i9Y'los-or
Floor .__ Apartment No.__ _No.Occupants
No.of Habitable Rooms — _ No.Sleeping Rooms
No.dwelling or rooming units ,_ No.Stories-_
Name and address of owner
Remarks Reg. Vio.
YARD Out Bldgs.: Fences:
Garbage and Rubbish:
Containers:
Drainage (It...,
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
•
Dual Egress: and Obst'n.:
0 B ❑ F 0 M Doors,Windows: /n/
Roof (f l(.i
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Ok—
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway: ___
i.
Obst'n.: 1 L i iQ �Kll L
o ...,
' Hall, Flo J, eiling. L?31C(5'7 r vie, (Atlb7
z Hall Li f . K.
i Hall Windows: 391 fo Irv'
HEATINW Chimneys: �l
W Central 0 N Equip. Rep
a TYPE: 0 Stacks, Flu s,Vents: NV gi �� �/
PLUMBING: Supply Line: Ill/,._-- nib f vt't�„
y 0 MS 0 ST 0 P Waste Line: I /.' ,
aa H.W.Tank(s)Safety and .,t ! Q� PM' Jd
= ELECTRICAL Panels, Meters,Cir.: 4(i$J(Y X -
❑ 110 0 220 Fusing,Grnd.: r A M,
AMP: Gen.Cond. Dist ! ..x: _ ...- _
o Gen. Basement i iring:
iL DWELLING UNIT
Ventil. Lgtng. Outlets Walls ' Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom .
Den ry nk_.---Living Room
Bedroom (1)
Bedroom (2)
Bedroom (3)
Bedroom (4) -
Hot Water Facil. - Sup.Ten.,6,Oil, Elect.: *"
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink &j>`
Stove
Bathing, Toilet Fact!. Vent., Plumb.,Sanit'n.:
6)k—
Wash Basin,Shower or Tub: —
Infestation Rats, Mice, Roaches or Other: _
Egress Dual and Obst'n:
General Building Posted:
Locks on doors:
ONE OR MORE OF THE VIOLATIONS CHECKED.ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHOR! ED INSPECTOR. (See Over)
INSPECTOR___ — TITLE
— A.M.
DATE -lam ��. —. TIME — A.M.
A.M.
THE NEXT SCHEDULED REINSPECTION _-_ P.M.