MN-S Emergency Repair Program

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

• Single Family Dwelling Inspection Form Version 3.0, Sept 2022

  Yes

  No

  N/A

• Occupant's Name:

• Building Type (i.e., mobile, bungalow):

# of Bedrooms in Unit:

• Year Built:

• Address:

Exterior

• Notes/Description (Problem, Cause, and Recommended Action)

• Grade (Around Foundation)

  Yes

  No

  N/A

• Foundation (Above Grade)

  Yes

  No

  N/A

• Water storage / Septic tanks / Oil Tank

  Yes

  No

  N/A

• Cladding / Wall Finish

  Yes

  No

  N/A

• Skirting (mobile homes)

  Yes

  No

  N/A

• Anchorage (mobile homes)

  Yes

  No

  N/A

• Flashing (Windows / Doors / Siding / Wall Finish)

  Yes

  No

  N/A

• Soffits / Fascia / Flashing

  Yes

  No

  N/A

• Eavestroughs / Downspouts /

  Yes

  No

  N/A

• Splashpads

  Yes

  No

  N/A

• Attic ventilation

  Yes

  No

  N/A

• Roof Surface

  Yes

  No

  N/A

• Chimney

  Yes

  No

  N/A

Steps / Landings

• Hand / Guard rails

  Yes

  No

  N/A

Balcony / Deck

Walkways

• Driveways / Parking

  Yes

  No

  N/A

• Entrance Doors

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Primary Heat Source - LIST AGE,

• FUEL TYPE, AND BTU

  Yes

  No

  N/A

Secondary Heat Source (if applicable)

– LIST AGE

• Date Last Serviced (if known)

  Date

Heat Distribution System

• HRV/ Air Exchanger

  Yes

  No

  N/A

• Clearance to Combustibles

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Systems – Heat/Ventilation

• Notes/Description (Problem, Cause, and Recommended Action)

Crawlspace/Basement

• Notes/Description (Problem, Cause, and Recommended Action)

Systems – Plumbing/Sewer

• Notes/Description (Problem, Cause, and Recommended Action)

Systems – Electrical

• Notes/Description (Problem, Cause, and Recommended Action)

Kitchen

• Notes/Description (Problem, Cause, and Recommended Action)

Basement / Crawl Space Floor

• Perimeter/Rim Joist Insulation

  Yes

  No

  N/A

• Foundation Walls / Grade beam

  Yes

  No

  N/A

• Columns / Beams / Joists

  Yes

  No

  N/A

Stairs / Handrails / Entrance

• Ventilation

  Yes

  No

  N/A

• Evidence of Water / Moisture Infiltration

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Sump Pump / Pit

• Water / Sewage pumps

  Yes

  No

  N/A

• Hot Water Tank – LIST AGE AND BTU

  Yes

  No

  N/A

• Drain / Supply lines

  Yes

  No

  N/A

• Exterior Hose Bib

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Fixtures

  Yes

  No

  N/A

• Switches / Receptacles

  Yes

  No

  N/A

• Smoke Detector / CO Detector

  Yes

  No

  N/A

• Electrical Panel

  Yes

  No

  N/A

• Meter Socket/Mast

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Cabinets/Countertops / Backsplash

  Yes

  No

  N/A

• Light fixtures

  Yes

  No

  N/A

• Sink / Faucets

  Yes

  No

  N/A

Flooring / Subfloor

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Receptacles / Switches

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

Flooring/Subfloor

Living Room

• Notes/Description (Problem, Cause, and Recommended Action)

• Hallway

  Yes

  No

  N/A

• Notes/Description (Problem, Cause, and Recommended Action)

Bathroom 1

• Notes/Description (Problem, Cause, and Recommended Action)

Bathroom 2

• Notes/Description (Problem, Cause, and Recommended Action)

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Light fixtures

  Yes

  No

  N/A

• Switches / Receptacles

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

Flooring/Subfloor

• Receptacles / switches

  Yes

  No

  N/A

• Light fixtures

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Vanity

  Yes

  No

  N/A

• Sink / Faucet

  Yes

  No

  N/A

• GFCI Plug

  Yes

  No

  N/A

Water Closet

• Tub / Shower / Faucets

  Yes

  No

  N/A

• Tub Surround / Enclosure

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Exhaust Fan

  Yes

  No

  N/A

Flooring/Subfloor

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Light fixtures/switches

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Vanity

  Yes

  No

  N/A

• Sink / Faucet

  Yes

  No

  N/A

• GFCI Plug

  Yes

  No

  N/A

Water Closet

• Tub / Shower / Faucets

  Yes

  No

  N/A

• Tub Surround / Enclosure

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Exhaust Fan

  Yes

  No

  N/A

Flooring/Subfloor

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Light fixtures/switches/

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Bathroom 3

• Notes/Description (Problem, Cause, and Recommended Action)

• Vanity

  Yes

  No

  N/A

• Sink / Faucet

  Yes

  No

  N/A

• GFCI Plug

  Yes

  No

  N/A

Water Closet

• Tub / Shower / Faucets

  Yes

  No

  N/A

• Tub Surround / Enclosure

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Exhaust Fan

  Yes

  No

  N/A

Flooring/Subfloor

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Light fixtures/switches

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Flooring/Subfloor

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Closet / Shelving

  Yes

  No

  N/A

• Receptacles / switches

  Yes

  No

  N/A

• Light fixtures

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Flooring/Subfloor

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Closet / Shelving

  Yes

  No

  N/A

• Receptacles / switches

  Yes

  No

  N/A

• Light fixtures

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Flooring/Subfloor

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Closet / Shelving

  Yes

  No

  N/A

Bedroom 1

• Notes/Description (Problem, Cause, and Recommended Action)

Bedroom 2

• Notes/Description (Problem, Cause, and Recommended Action)

Bedroom 3

• Notes/Description (Problem, Cause, and Recommended Action)

Bedroom 4

• Notes/Description (Problem, Cause, and Recommended Action)

Interior - General

• Notes/Description (Problem, Cause, and Recommended Action)

• Receptacles

  Yes

  No

  N/A

• Light fixtures / switches

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Flooring/Subfloor

• Wall Finish

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Windows (with # to be replaced)

  Yes

  No

  N/A

• Closet / Shelving

  Yes

  No

  N/A

• Receptacles

  Yes

  No

  N/A

• Light fixtures / switches

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Stairs / Handrails

  Yes

  No

  N/A

• Ceiling Finish

  Yes

  No

  N/A

• Wall Finish

  Yes

  No

  N/A

Flooring / Subfloor

• Built-In Closets / Storage / Shelves

  Yes

  No

  N/A

• Evidence of Water / Moisture Infiltration

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Overall Condition of Home

  Yes

  No

  N/A

• Excellent ☐

• Above Average ☐

• Below Average☐ Poor☐

• Would the cost of repairs be estimated at 75% or more of a replacement cost? ☐No ☐Yes

  Yes

  No

  N/A

• Disability/Accessibility

  Yes

  No

  N/A

• Priority Legend

  Yes

  No

  N/A

• ST:

  Yes

  No

  N/A

• MT:

  Yes

  No

  N/A

• LT:

  Yes

  No

  N/A

• AD:

  Yes

  No

  N/A

Urgent, Immediate

• Short Term, within 1 year

  Yes

  No

  N/A

• Medium Term, from 1 to 3 years

  Yes

  No

  N/A

• Long Term, from 3 to 5 years

  Yes

  No

  N/A

• ADEQUATE: Longer than 5 years

  Yes

  No

  N/A

• Inspector Name:

• Inspector Signature:

  Sign

• Inspector Phone #:

• Inspection Date:

  Date