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nregon Department of Trans ~fation ,,~,,'.ELOCATION <br />REPLACEMENT DWELLINc~ ~INSPECTION <br />Replacement P~operty Address <br />Type of Dweiling: <br />^ SFR ^ Dup~,Apt. ^ MH ^ Other <br />__ ~__ Adult Males ___ _ Adult Females <br />_____ Male Child~en _____ Female Children <br />__~__ Bedrooms _ ~~__ Total Rooms 1U~_ Total Area <br />~ City Water ^ Private Well ^ Other <br />~ Structure sound and weather tight <br />Safe and adequate electrical system <br />Clean and sanitary <br />Heating capable of siastaining 70 F <br />Unobstructed safe ingress and egress <br />In good repair <br />Adequate size with respect to number of <br />rooms and living space <br />~ Multiple family dwellings: if 2 or more stories, <br />if apa~tme~ts enter onto two exits <br />Appears to meet local housing, occupancy codes <br />~,~ No apparent bamers to handicapped, if.applicable <br />KITCHEN AREA <br />~ Separate room or area for kitchen use <br />Sink in working order <br />`~ Proper connection to sewage system <br />'~ Proper connection to potable hot & cold water <br />Range (stove) space with utility connections <br />Refrigerator space with utility connections <br />BATHROOMS <br />~ Separate room properly lighted & ventilated <br />Functional sink (basin) <br />Privacy for users <br />Functional flush toilet <br />~ Functional bathtub or shower stall <br />~ Water & sewage plumbing in working order <br />File No. <br />Name <br />Section <br />Highway <br />Counry <br />FAP No. <br />STAPLE PHOTO HER.E <br />I, the undersigned, have inspected the proposed replacement dwelling unit at the address shown in the heading of this form. The <br />inspection was made solely to determine if the dwelling will qualify this displacee to receive a replacement housing payment by the <br />agency. TO THE BEST OF MY KNOWLEDGE AND BELIEF, this dwelling ~ MEETS DOES NOT MEET the agency's <br />standards for qualified replacement housing. <br />Remarks <br />8 <br />Right- of Way Agent <br />Relocatee Disclaimer Statement <br />I understand that the above observations made by the Right of Way Agent are made solely for the purpose of determining <br />eligibility for relocation assistance on replacement housing in accordance with Oregon Department of Transportation <br />regulations. They do not constitute warrants or guarantees by the Depa~tment of Transportation. <br />~ L qe rin ormat available <br />- - - ~ ~ <br />Relocatee Date <br />Relocation <br />Form 107 (6/95) Replacement Dwelling Inspection <br />