Credit Card #
Name on card
Exp. date CVS
Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
P. 216-641-4654 F. 216-541-2712 E. kpagsuyoin@newburgh-oh.gov
2021 Point of Sale Application
Incomplete forms will not be accepted.
The Point of Sale inspection will expire one (1) year from the time of inspection. If the violations have not been
corrected prior to the expiration of the Point of Sale inspection a new Point of Sale may be required.
Property Information
PROPERTY ADDRESS:
Type of Dwelling Single-Family Two-Family Multi-Family Commercial
If this is a Rental Property, are tenants currently living there? Yes No
Email Receipt? Yes No
Owner Information
Name:
Property Owner Address:
City: State: Zip Code: Phone:
Alt. Phone: Email:
Real Estate Agent/Property Management Company Information
Name of Real Estate/Property Management Company:
Name of Primary Contact/Manager:
Address: City: Zip Code:
Business Phone: Primary Contact Phone:
Email Address of Primary Contact:
Disclaimer for Point of Sale Inspection
Applicant Signature: Date:
Payment Information (for office use only)
A nonrefundable fee of $150.00 (first unit, single family) and $50.00 for each additional unit must accompany this application. Make check payable to
the Village of Newburgh Heights. Do not send cash. Additionally, it is the applicant’s responsibility to schedule the inspection with the Housing and
Building Department, 216-641-2716.
Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
P. 216-641-4654 F. 216-541-2712 E. kpagsuyoin@newburgh-oh.gov
2021 Point of Sale Application
Incomplete forms will not be accepted.
The Point of Sale inspection will expire one (1) year from the time of inspection. If the violations have not been
corrected prior to the expiration of the Point of Sale inspection a new Point of Sale may be required.
Property Information
PROPERTY ADDRESS:
Type of Dwelling Single-Family Two-Family Multi-Family Commercial
If this is a Rental Property, are tenants currently living there? Yes No
Email Receipt? Yes No
Owner Information
Name:
Property Owner Address:
City: State: Zip Code: Phone:
Alt. Phone: Email:
Real Estate Agent/Property Management Company Information
Name of Real Estate/Property Management Company:
Name of Primary Contact/Manager:
Address: City: Zip Code:
Business Phone: Primary Contact Phone:
Email Address of Primary Contact:
Disclaimer for Point of Sale Inspection
Applicant Signature: Date:
Payment Information (for office use only)
A nonrefundable fee of $150.00 (first unit, single family) and $50.00 for each additional unit must accompany this application. Make check payable to
the Village of Newburgh Heights. Do not send cash. Additionally, it is the applicant’s responsibility to schedule the inspection with the Housing and
Building Department, 216-641-2716.
Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
P. 216-641-4654 F. 216-541-2712 E. kpagsuyoin@newburgh-oh.gov
2021 Point of Sale Application
Incomplete forms will not be accepted.
The Point of Sale inspection will expire one (1) year from the time of inspection. If the violations have not been
corrected prior to the expiration of the Point of Sale inspection a new Point of Sale may be required.
Property Information
PROPERTY ADDRESS:
Type of Dwelling Single-Family Two-Family Multi-Family Commercial
If this is a Rental Property, are tenants currently living there? Yes No
Email Receipt? Yes No
Owner Information
Name:
Property Owner Address:
City: State: Zip Code: Phone:
Alt. Phone: Email:
Real Estate Agent/Property Management Company Information
Name of Real Estate/Property Management Company:
Name of Primary Contact/Manager:
Address: City: Zip Code:
Business Phone: Primary Contact Phone:
Email Address of Primary Contact:
Disclaimer for Point of Sale Inspection
Applicant Signature: Date:
Payment Information (for office use only)
A nonrefundable fee of $150.00 (first unit, single family) and $50.00 for each additional unit must accompany this application. Make check payable to
the Village of Newburgh Heights. Do not send cash. Additionally, it is the applicant’s responsibility to schedule the inspection with the Housing and
Building Department, 216-641-2716.
Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
P. 216-641-4654 F. 216-541-2712 E. kpagsuyoin@newburgh-oh.gov
2021 Point of Sale Application
Incomplete forms will not be accepted.
The Point of Sale inspection will expire one (1) year from the time of inspection. If the violations have not been
corrected prior to the expiration of the Point of Sale inspection a new Point of Sale may be required.
Property Information
PROPERTY ADDRESS:
Type of Dwelling Single-Family Two-Family Multi-Family Commercial
If this is a Rental Property, are tenants currently living there? Yes No
Email Receipt? Yes No
Owner Information
Name:
Property Owner Address:
City: State: Zip Code: Phone:
Alt. Phone: Email:
Real Estate Agent/Property Management Company Information
Name of Real Estate/Property Management Company:
Name of Primary Contact/Manager:
Address: City: Zip Code:
Business Phone: Primary Contact Phone:
Email Address of Primary Contact:
Disclaimer for Point of Sale Inspection
Applicant Signature: Date:
Payment Information (for office use only)
A nonrefundable fee of $150.00 (first unit, single family) and $50.00 for each additional unit must accompany this application. Make check payable to
the Village of Newburgh Heights. Do not send cash. Additionally, it is the applicant’s responsibility to schedule the inspection with the Housing and
Building Department, 216-641-2716.
Seller’s Title Company
Name of Title Company:
Name of Primary Contact:
Primary Contact Number: Primary Contact Email:
Title Search Yes No Name of Title Company:
Primary Contact: Phone number:
Date of Inspection: Time:
Village of Newburgh Heights
Housing & Building Department
3801 Harvard Avenue, Newburgh Heights, OH 44105
P. 216-641-4654 F. 216-541-2712 E. kpagsuyoin@newburgh-oh.gov
2021 Point of Sale Application
Incomplete forms will not be accepted.
The Point of Sale inspection will expire one (1) year from the time of inspection. If the violations have not been
corrected prior to the expiration of the Point of Sale inspection a new Point of Sale may be required.
Property Information
PROPERTY ADDRESS:
Type of Dwelling Single-Family Two-Family Multi-Family Commercial
If this is a Rental Property, are tenants currently living there? Yes No
Email Receipt? Yes No
Owner Information
Name:
Property Owner Address:
City: State: Zip Code: Phone:
Alt. Phone: Email:
Real Estate Agent/Property Management Company Information
Name of Real Estate/Property Management Company:
Name of Primary Contact/Manager:
Address: City: Zip Code:
Business Phone: Primary Contact Phone:
Email Address of Primary Contact:
Disclaimer for Point of Sale Inspection
Applicant Signature: Date:
Payment Information (for office use only)
A nonrefundable fee of $150.00 (first unit, single family) and $50.00 for each additional unit must accompany this application. Make check payable to
the Village of Newburgh Heights. Do not send cash. Additionally, it is the applicant’s responsibility to schedule the inspection with the Housing and
Building Department, 216-641-2716.
I agree and consent to an inspection to be conducted by a designee
of the Village at the agreed upon date and time as scheduled with the
Housing & Building Department and understand missed inspections may
accrue a fee. I agree to make all areas of the property accessible for
inspection.
I understand that I will be responsible for all coded violations found at
the time of inspection. The buyer may apply to assume the violations;
the Housing & Building Department will then review the applications and
make a determination. I further understand that if I chose NOT to sell
my property, all violations identied in this inspection shall be corrected
within the time specied by the Housing and Building Department.
I understand that neither The Village of Newburgh Heights nor its represen-
tatives assume any liability or responsibility for failure to report/or discover
any violation(s). I agree to inform all perspective buyers that an inspection
by Newburgh Heights does not guarantee that all property defects and/or
code violations have been discovered. Furthermore, violations may devel-
op after this inspection. The purpose of this inspection is for The Village at
large and not intended to protect the interests of any individual, owner or
successor owner or occupant of real property.
For Rental Properties Only: I understand if the Point of Sale inspection is
standing for my rental inspection that I will require a rental inspection if a
change of tenant occurs and will contact the Housing & Building Depart-
ment to schedule an inspection.
Total Amount Paid:
Cash
Check #
Payment made online
