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
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Address of Property Owner:
113)5g4- 15g6
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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
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