Date:
Owner: Phone:
Mailing Address:
Property Address:
Maximum Occupancy Per Unit: Actual Number of Occupants:
Name of Current Tenants:
Is This Building Commercial or Residential?
Name of Property Manager: Phone:
Emergency Contact: Phone:
*** Fees for occupancy inspections are as follows: Residential Tenant Space -
$75
Commercial Tenant Space -
$100
Make check or money order payable to BHW Construction Consultation Services, Inc.
To schedule this inspection please call BHW at 570-270-3900
*** Fill out ONLY applicable blocks. If unknown, leave blank.
Jackson Township Rental Inspection Application
1275 Huntsville Rd., Jackson Township, PA 18708
Phone: 570-675-8371 Fax: 570-675-1590
Signature of Owner or Authorized Agent
Print Name of Owner or Authorized Agent
I certify that the code administrator or the code administrator's authorized representative shall have the authority
to enter areas required for this inspection at any reasonable hour to enforce the provisions of the code(s) applicable
to such inspection. I also understand that this inspection is a visual, non invasive inspection only, and therefore hold
harmless both BHW Construction Consultation Services, Inc., and Jackson Township for anything that may happen
within the property after the inspection.
click to sign
signature
click to edit
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