Division of Professional Licensure
Office of Public Safety and Inspections
1000 Washington Street, Suite 710, Boston, MA 02118
REQUIRED INFORMATION IS HIGHLIGHTED
First and Last Name Phone Number E-mail
Address of Testing Site City/Town Zip Code
Mailing Address □ Same as Above
City/Town State Zip Code
Type of Property
□ Residential □ Condo □ House Addition
Year Built Year Addition Built
Type of Foundation Test
□ Visual □ Core Test
Date Test
Conducted
Total Invoice Amount Number of Cores
Company/Engineer Name Phone Number E-mail License Number
(If available)
Optional Questions
Did your foundation test positive for pyrrhotite? □ YES □ NO □ I don’t know
Damage Level (If given)
□ No Visible Damage □ Minor Degradation □ Minor to Moderate Degradation
□ Moderate to Severe Degradation □ Severe Degradation □ I don’t know
Where is the location of the damage?
□ Concrete Floors Only □ Concrete Wall Only □ Floors and Walls □ I don’t know
Does your house have any of the following characteristics? (Check all that you know, skip if you don’t know.)
□ Waterproofing on the exterior of the basement □ Routine use of dehumidifier in the basement
□ Waterproofing in the interior walls □ Gutters
□ Finished Basement or partially finished □ Damage was in the partially finished portion
Please enclose the following to complete your application:
□ Proof of Home Ownership (Condos: proof of foundation ownership - usually the association declaration)
(Examples of homeownership include mortgage statements, tax bills, copies of deeds, etc.)
□ Testing / Visual Inspection Report / Results
□ Pictures of Foundation Damage (If not in Report)
□ Invoice or other Documentation of Costs (Such as a cancelled check)
□ Dated Records of House Addition (If applicable)
□ List of Other Units that Share Foundation (For Condos)
I certify that the information entered above is complete and accurate.
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Mail applications to:
Office of Public Safety & Inspections, Crumbling Foundations
1000 Washington Street, Boston, MA Suite 710, Boston, MA 02118
Question to Cesar.Lastra@Mass.gov or call 617-826-5202.
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