80 apt 18 MRVP Report 1998 4/f37cattail
BOARD OF HEALTH CITY OF NORTHAMPTON "�• •��
MEMBERS ' Y f
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MASSACHUSETTS 01060 reaakil '".'� ' c
JOHN T.JOYCE,Chairman 1 . � ��
ANNE BURES,M.D. : "
CYNTHIA DOURMASHKIN, R.N.
PETER J. McERLAIN,Health Agent
OFFICE OF THE 210 MAIN STREET
(413)587-1214 BOARD OF HEALTH NORTHAMPTON,MA 01060
FAX(413)587-1264
APPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR
MASSACHUSETTS RENTAL VOUCHER PROGRAM
Name of Property Owner: Date: `7/2.
Address of Property Owner: - L ;-(;, ., �� . Tel: E4-r-3)-L-13 f
4 0 OC ZSR-q`1.
(1) I herewith request a Housing Code Inspection and Certification of Fitness for Hun
Habitation for the following ( i ) apartment(s). (Give the total number of apartments tc
inspected)
(2) Was dwelling Constructed
Prior to 1978? Yes El No ❑ Signature of Owner
(3) Street Address: �D � -r-c ' 4r-ee kj 4z-14-., Or 060
(A) Apartment #: l g Occupant's Name& Phone#:
Children under six(6)years old Yes Es3 No D Loin 4e Ace v t•r't) Qf13)
(B) Apartment #: Occupant's Name& Phone#:
Children under six(6)years old Yes ❑ No ❑
(C) Apartment #: Occupant's Name & Phone #:
Children under six(6)years old Yes 0 No ❑
(D) Apartment #: Occupant's Name& Phone#:
Children under six (6)years old Yes ❑ No 0
(E) Apartment #: Occupant's Name& Phone#:
Children under six (6)years old Yes ❑ No ❑
(If necessary, attach additional sheets to this application if more apartments are to be listed.)
(4) Enclosed is a check for $ � 00 for 1 inspections. ( @ $75-00 per apartmer
(5) NOTE: If the dwelling(s) to inspected were constructed prior to 1978 and any children under
age of six (6) years reside there, you MUST have a Licensed Lead Paint Inspec
certify, in writing, that the property is in compliance with the State Lead Paint Law
760 CMR 49.04 (13). A Copy of this Lead Paint Certification Report must be f
with the Board of Health prior to issuance of the MRVP Certification letter.
(6) Return this application to: Northampton Board of Health
voct
City Hall, 210 Main Street
Northampton, MA 01060
MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTON