MASS DPS Inspection Certificate Form PDF Details

In the Commonwealth of Massachusetts, the Department of Public Safety (DPS) provides a crucial Application for Certificate of Inspection essential for both new and existing buildings or locations to ensure they meet safety and regulatory standards. This form, reflecting updates as of October 3, 2008, including revised inspection fees, must be meticulously completed and submitted in alignment with Massachusetts General Law (MGL) Chapter 111 §§ 51 and 71 and 780 CMR, the State Building Code. It outlines a comprehensive procedure that building owners and managers must follow to secure a certificate of inspection, vital for premises including those that serve alcohol on-site and public swimming pools, stipulated under MGL Chapter 140 § 206. Submission of the completed application, alongside the required fee to the Department of Public Safety, initiates a process that includes a building inspection by a DPS inspector and, if applicable, a fire safety inspection by municipal fire services. The details presented in the form—ranging from the address and use of the premise, the owner of record, and the contact person to the fee schedule based on the type of facility and its use—highlight the stringent steps and protocols in place to ensure the inspected premises are safe and compliant with all relevant laws and regulations in Massachusetts.

QuestionAnswer
Form NameMASS DPS Inspection Certificate Form
Form Length2 pages
Fillable?Yes
Fillable fields62
Avg. time to fill out12 min 54 sec
Other namesdps massachusetts, mass dps inspection, dps massachusetts form, massachusetts application certificate inspection

Form Preview Example

Commonwealth of Massachusetts

Department of Public Safety (DPS)

Application for Certificate of Inspection

APPLICATION FOR CERTIFICATE OF INSPECTION

PROCEDURES

s:\dps\webload\active website forms\certificate of inspection application revised 07-09.docx

Attached, please find a Department of Public Safety (DPS) Application for Certificate of Inspection for a new or existing building or location. Please note that effective October 3, 2008, inspection fees have been revised.

The application must be completed pursuant to Massachusetts General Law (MGL) Chapter 111 §§ 51 and 71 and 780 CMR (The State Building Code, Section 106 and Table 106. (Also see MGL Chapter 140 § 206 for Public Swimming Pools.)

Following an inspection by a Department of Public Safety Building Inspector, please mail the “completed” application along with a check payable to the Commonwealth of Massachusetts to the following address (State-owned buildings and locations are exempted from fees):

Department of Public Safety

1380 Bay Street, Building B

Taunton, MA 02780

Attention: Linda Shea

Phone Number: (508) 880-4930 Fax Number (508) 880-4931

E-mail address: Linda.Shea@state.ma.us

Please Note:

1.Application forms with accompanying fee must be filed for each building or structure or part thereof that is to be inspected and certified.

2.Completed Applications with appropriate fees must be received by the Department of Public Safety (DPS) prior to the issuance of a certificate of inspection. A certificate of inspection will not be issued until the application and fee has been received and processed by the Department of Public Safety.

3.Certificates for premises that serve alcohol on-site must also be inspected by a representative from the municipal fire department. It is the responsibility of the certificate applicant to contact municipal fire services to schedule a fire safety inspection. Failure to call for an inspection by fire services may cause a delay in the issuance of a Department of Public Safety (DPS) certificate of inspection.

4.Inspection requests must be received by the Department of Public Safety (DPS) at least thirty (30) days prior to the expiration of a current certificate.

Commonwealth of Massachusetts

Department of Public Safety (DPS)

Application for Certificate of Inspection

In accordance with the provisions of Massachusetts General Law Chapter 111 and\or 780 CMR (The State Building Code), Table

106, I herby apply for a Certificate of Inspection for the below-named premise located at the following address:

Address of Premise

Street Name

 

 

 

 

 

and Number

 

 

 

 

 

City\Town

 

 

Zip Code

 

 

 

 

 

 

 

Purpose for which premise is used

 

 

 

 

 

 

 

 

 

 

 

Certificate to be issued to

 

 

 

 

 

Identify exact name of premise to be

 

 

 

 

 

printed on certificate

 

 

 

 

 

Owner of Record

 

 

 

 

 

 

 

 

Contact Person

Contact Name

Contact Phone Number

Please indicate the person

 

 

 

 

 

responsible for assuring inspections

Title

Contact E-Mail Address

are completed

 

 

 

 

 

 

 

 

Signature of person to whom the

Print Name and Title

Signature

Certificate of Inspection shall be

 

 

 

 

 

issued

 

 

 

 

 

FEE SCHEDULE & CERTIFICATE INFORMATION

Please enclose a copy of the expired DPS certificate for all existing locations.

Please provide the DPS Tag

Tag Number

Is this a New Facility?

Is this an Existing Facility?

Number if known

 

 

Yes

 

 

No

 

Yes

 

No

 

 

 

 

 

 

 

 

 

Certificate of Inspection

Frequency

Fee

 

Number of units

 

Total Fee

Group Residences

Biennial

$200.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinics, Infirmaries

Biennial

$200.00

 

 

 

 

 

 

 

 

 

(Institutional Buildings)

 

 

 

 

 

 

 

 

 

 

 

Hospitals-First 100 Beds

Biennial

$200.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Each Additional 25 Beds

 

$ 10.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day Care Centers

Annual

$ 100.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assemblies

Annual

$ 100.00

 

 

 

 

 

 

 

 

 

(1 to 500 occupants)

 

 

 

 

 

 

 

 

 

 

 

Each additional 200 occupants

 

$ 10.00

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Fee Submitted

Return this application with a check made payable to the Commonwealth of Massachusetts to:

Department of Public Safety

1380 Bay Street, Building B

Taunton, MA 02780

Attention: Linda Shea

Inspected

By

Date

Inspected

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