Home owners name:
Residence address :
Mailing address if different:
City:
State/Zip:
Telephone:(hm) (wk)
Email address:
Is your home a house, condo, townhome:
House
Condo
Townhome
Sq. Ft. Home/condo/townhome
Number of units complex
Purchase date of your home:
Are you renting your home:
Yes
Please Briefly Describe The Problems You Are Encountering :
Yes
No
1. Have you repaired any construction problems in your residence?
2. Has the home owner’s association done any repairs on your
home?
3. If repairs have been done, did it fix the problem?
4. Do you have roof leaks?
5. Have you had roof leaks in the past?
6. Do you have damp ceiling?
7. Do you have stained ceiling?
8. Do you have mold on your ceiling?
9. Discoloration of roof or eaves?
10. Do you have problems with gutters and or downspouts?
11. Are there any stains or leaks that you know of, below a balcony, deck
or window?
If yes, explain:
12. Do you have standing water, , i.e. ponding,
on your it, or after
it rains?
13. Does water on your deck / balcony not drain
properly?
14. Is the surface of your balcony / deck separating,
splitting, coming up or damaged i n any way?
15. Do any of your windows leak?
16. Have your windows leaked in the past?
If yes, explain:
17. If yes, were they fixed?
If yes, explain:
18. Are your window-sills stained?
19. Do you have mildew or mold around or near
your windows?
20. Do you have cracks in your drywall or stucco?
If yes, where?
21. Do you have cracks in any of your ceilings?
If yes, where?
22. Do any of your walls have mold or mildew
on them?
If yes, how
many and where?
23. Does any part of your house sometimes smell
of must or mildew?
If yes, where?
24. Are any of your walls damp or discolored
(water stains)?
If yes, where?
25. Are any of your carpets sometimes wet or
have an odor?
If yes, where?
26. If yes, does anyone residing in your home have respiratory problems
or been ill more than normal since moving into your home?
If yes, describe:
27. If you have children, have they been out
of school more than normal since moving into your home,
especially as a result of respiratory ailments?
28. Is your paint peeling anywhere in the interior
of your home?
29. Do you have any cracks in walls over doorways?
30. Do you think that your air-conditioning
system is adequately cooling your home?
31. Do you think that your heating system is
adequately heating your home?
32. Do you now have plumbing problems?
33. Have any of your pipes or pipe joints failed
in your home, o r inordinate amount of
leaking?
34. Do you hear knocking or vibrations, from
your plumbing?
35. Have you had property damage or loss from
plumbing leaks?
36. Have you ever had any electrical problems
in your home?
If yes, describe:
37. Have any of your outlets failed to work?
38. Have you ever had the loss of electrical
power due to the circuit at the electrical panel?
40. Do you have any other electrical problems?
If yes, explain:
41. Do you have any cracks in your stucco?
If yes, give
location
42. Is any of your stucco uneven in color?
43. Are there stucco cracks around any of your
windows?
44. Are there stucco cracks around any of your
door frames?
45. If a condo/townhouse, have you noticed any
problems with common areas
If yes, where?
46. Are there roots buckling concrete flatwork?
If yes, where?
47. Have you noticed any problems with any concrete
and or retaining walls?
If yes, where?
48. Are you aware of any cracks or movement
of curbs on or near your home or unit?
If yes, where?
49. Are you aware of any cracks or movement
of curbs in your complex?
If yes, where?
50. Have you seen cracks in exterior foundations?
51. Do you have cracks in your garage ceiling?
52. Have you noticed areas, where there are
tripping hazards?
53. Do you know of any ponding or pooling of
water on or around your property?
54. Do you have any other miscellaneous
constructions problems not mentions above, describe:
