EOED-DOL

Name of Municipality(Required)

Building Department Telephone Number(Required)

Building Department Fax Number

Submitter's Municipal Email Address(Required)

Building Department Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Please include ONLY those persons working in the Building Department as either – Inspector of Buildings/Building Commissioner, or Local Inspector. DO NOT include plumbing, wiring, gas or alternate building inspectors.

Building Official Names(Required)

Use the "+" symbol to add more than one building official.

Name of all Building Officials

Title: Building Commissioner or Local Inspector

Part Time

Full Time

Is the Inspector Certified as Required by MGL c 143 § 3

Date of Original Appointment

Building Official Number

Completed By:(Required)

First Last

Date Completed:(Required)

Today's Date: