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2. ABANDONED BUILDING PRIMARY ASSESSMENT
3. DATE*
   DATE

   DATE
5. Address1*
7. Address2
9. City
10. State
11. Zip
13. OWNER INFORMATION
15. First Name
16. Last Name
18. Telephone Number Primary
19. Telephone Number Secondary
21. Building Use
    -- Select One --CommercialResidential
23. Address1
24. Address2
26. City
27. State
28. Zip
30. OCCUPIED OR RECENT ACTIVITY
32. Does it appear to be occupied?*
    -- Select One --YesNo
34. Does it appear to be in disrepair?*
    -- Select One --YesNo
36. DOES THE BUILDING APPEAR TO HAVE ANY MAJOR CONSTRUCTION DEFECTS?
38. Roof Intact*
    -- Select One --YesNo
40. Broken Windows*
    -- Select One --YesNo
42. Major Structural Deteriorations*
    -- Select One --YesNo
44. Utilities Active*
    -- Select One --YesNo
46. LAND AND VEGETATION CONDITIONS AROUND THE BUILDING
48. Describe
50. COMBUSTIBLES NEAR OR AROUND THE OUTSIDE OF THE STRUCTURE
52. Describe
54. TYPE OF MOST RECENT USE OF THE STRUCTURE
56. Describe
58. Additional Comments
60. Person Completing Assessment*
61. Employee #*
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field