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Oregon Department of Tra ~ortation `~ RELOCATION <br />' REPLACEMENT DWELLING INSPECTION <br />Replacement Properly Address <br />ryPeof~weu~~9: ~ SFR Q Dup ~Apt. ~( MH Q Other <br />_~___ Adult Males __~__ Adult Females <br />Male Children _____ Female Children <br />_~__ Bedrooms _,~ __ Total Rooms _____ Totai Area <br />City Water ^ Private Well ^ Other <br />tructure sound and weather tight <br />Safe and adequate electrical system <br />Clean and sanitary <br />,~Heating capable of sustaining 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 apartments enter onto two exits <br />~Appears to meet local housing, occupancy codes <br />^ No apparent barriers 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 />~tefrigerator space with utiliry connections <br />BATHROOMS <br />Separate room properly lighted & ventilated <br />Functional sink (basin) <br />Privacy for users <br />unctional flush toilet <br />~unctional bathtub or shower stall <br />Water & sewage plumbing in working order <br />File No. <br />Name <br />Section <br />Highway <br />County <br />FAP No. <br />STAPLE PHOTO HERE <br />I, the undersigned, have inspected the proposed replacement dwelling unit at the ddress shown in the heading of this form. The <br />inspection was made solely to determine if the dwelling will qualify this displace 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 />~ Right- of Way Agent • uate <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 n t nstitute warrants or guarantees by the Department of Transportation. <br />~ , Large print format available <br />~? ~.~ ~-/ 7-~) <br />Relocatee <br />Date <br />Relocation <br />Fortn 107 (6/95) Replacement Dwelling Inspection <br />