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.
| Question | Answer |
|---|---|
| Form Name | MASS DPS Inspection Certificate Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 62 |
| Avg. time to fill out | 12 min 54 sec |
| Other names | dps massachusetts, mass dps inspection, dps massachusetts form, massachusetts application certificate inspection |
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
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
Department of Public Safety
1380 Bay Street, Building B
Taunton, MA 02780
Attention: Linda Shea
Phone Number: (508)
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
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
Address of Premise |
Street Name |
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and Number |
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City\Town |
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Zip Code |
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Purpose for which premise is used |
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Certificate to be issued to |
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Identify exact name of premise to be |
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printed on certificate |
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Owner of Record |
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Contact Person |
Contact Name |
Contact Phone Number |
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Please indicate the person |
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responsible for assuring inspections |
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Contact |
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are completed |
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Signature of person to whom the |
Print Name and Title |
Signature |
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Certificate of Inspection shall be |
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issued |
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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? |
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Number if known |
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Yes |
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No |
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Yes |
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No |
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Certificate of Inspection |
Frequency |
Fee |
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Number of units |
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Total Fee |
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Group Residences |
Biennial |
$200.00 |
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Clinics, Infirmaries |
Biennial |
$200.00 |
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(Institutional Buildings) |
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Biennial |
$200.00 |
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Each Additional 25 Beds |
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$ 10.00 |
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Day Care Centers |
Annual |
$ 100.00 |
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Assemblies |
Annual |
$ 100.00 |
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(1 to 500 occupants) |
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Each additional 200 occupants |
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$ 10.00 |
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Residential |
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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
s:\dps\webload\active website forms\certificate of inspection application revised