Loading...
491 Application for Housing Inspection 2016 BOARD OF HEALTH MEMBERS DONNA C.SALLOOM,CHAIR JOANNE LEVIN,M.D. SUZANNE SMITH,M.D. CYNTHIA SUOPIS,PhD WILLIAM HARGRAVES STAFF Menidith O'Leary,RS,Director Lisa Steinbock,R.N.,Public Health Nurse Daniel Wasiak,Health Inspector Edmund Smith,Health Inspector CITY OF NORTHAMPTON MASSACHUSETTS 01060 OFFICE OF THE HEALTH DEPARTMENT 212 MAIN STREET NORTHAMPTON,MA 01060 APPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR MASSACHUSETTS RENTAL VOUCHER PROGRAM f yeadbIc - Wi` (("YPS QiSDCir Date: 1/G * b Address of Property Owner: 113)5g4- 15g6 t 1r o»el,yY7f} Dlbioa Name of Property Owner: (1) I herewith request a Housing Code Inspection and Certification of Fitness for Human Habitation for the following ( 2 ) apartment(s). (Give the total number of apartments to be inspected) (2) Was dwelling Constructed Prior to 1978? (3) Street Address: Yes x No (A) Apartment#:/00a., Yes 'g, No ❑ Occupant's Name&Phone#: Mill 1arChltWri_ Children under six(6)years old (B) Apartment#: Yes ❑ No ❑ Occupant's Name&Phone#: Children under six(6)years old (C) Apartment#: Yes ❑ No ❑ Occupant's Name&Phone#: Children under six(6)years old (D) Apartment#: Yes ❑ No ❑ Occupant's Name&Phone#: Children under six(6)years old (E) Apartment#: Yes ❑ No ❑ Occupant's Name&Phone#: Children under six(6)years old (4) (5) (6) (If necessary,attach additional sheets to this application if more apartments are to be listed.) Enclosed is a check for$ 75; for 4. inspections. ( @$75.00 per apartment. ) NOTE: If the dwelling(s) to inspected were constructed prior to 1978 and any children under the age of six (6) years reside there, you MUST have a Licensed Lead Paint Inspector certify, in writing, that the property is in compliance with the State Lead Paint Laws — 760 CMR 49.04 (13). A Copy of this Lead Paint Certification Report must be filed with the Board of Health prior to issuance of the MRVP Certification letter. Return this application to: Northampton Board of Health 212 Main Street Northampton, MA 01060 MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTON 1A Sc° �_�h�