71 Unit 325 Complaint �1R, , zt-
T�-_:; Trzcl:inC�' Entered 3t': e,fei
BODY ART_
CH
FOOD
ODOR
'RATER SEWER
COMFL4INTANT'S INFO
Complainant's Name:
Occupant's Name:
Complaint Location:
NATURE OF
COMPLAINT:
FOOD ILLNESS
PESTS
HOARDING
MAT[ON:
Date Entered: G1/414
HOUSING NAIL SALONS
POOLS SEPTIC
OTHER
Call Taker Initials: C-R C
Date of Complaint: l ) (p
Telephone r�Q-�/���Q-' y�U QZ1�
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a
upant Name
iress
ner Name
rner Address
pector
Northampton Health Department
212 Main Street
Northampton,
MA 01060 64 ctn.,. o
(413)597-1214
Inspection Form
State Sanitary Code 105 CMR 410.000:
Chapter II,Minimum Standards of Fitness for Human Habitation hildren<6 Years
Time am/pm N occupants
Phone
City/Town
Phone*
City/Town
lm r
con
Locks,striker mechanism(4 or more uni
i Costing.ID,Exit signs/emergency ugh
Title -
Handrails,steps,doors,windows roof-maintenance
Weather tight elemen
Rubbish-storage and collection
debris,vegetation
H-
eard ard maintenance-
on Maintenance of area
on tenant
f Doors,tights,windows-weather tight,main
y I
Egress-means,obstructed,sate
Handrail provided,maintenance
Lights
e S
Gloop W I�alts,ceiling-maintenance
in I,
1 Railings,stairs
Doors,windows-weather tight,maintenance
ch
Location(circle):
I Refrigerator s
''. and smooth
r Floor,walls,ceiling-maintenance
Outlets,lights
1. Windows,screens-weather tight lock,maintenance,
provided
Non-absorbent floor
Apt II
Zip Code
480
81,483.484
500.503
501
600,601
602
450.451,452
MIMS
MINNI
®�
503.500 _-
®-
Front Rear Middle Floor Level of Unit
00 t \ La
254
5W
Ink,stove,oven-good repair,imperwou
mg room Floo,walls,ceiling
if outlets,lights
Windows, lock,weather tight,maintenance,
provided
500
251
50 480,500,
551
504
500
250
501,480-500.
551
MIN
NNW
C � stfiSir
4
of
doors,walls,ceiling
Dutlets,lights
Windows screens—weather tight,locks,maintenance
provided
Floors,walls,ceiling
Outlets,lights
Windows,screens—weather tight,to
prodded
F oars,walls,ceiling
Outlets,lights
Windows,screen
I provided
Sink,shower,tub
Lights,outlets
maintenance,
4 2,M✓I(ourLir
NEM era
500
250
500
250
250
her tight,locks,maintenance, 501 480, 500
551
0,500
pervious,maintenance
Vent lat�mechanical
Floors, ceiling—maintenance
ai ntenance,weathertight
Ugh
I- Fuel Type lcirclel: Public Private
Potable,quantity.pressure
IPlesPonsible for paying MGL ch 186 s 22,metering
Oil
ng
r I Fuel Type(circle): Natural Gas
I °f Location taken:
Temp.:
•110 f min-130 max°5
g II- Type(circle): Forced Hot Water Forced Hot Air
I Steam Electric
No portable units
250
NMI
500.50
25
80,354
Electric Other
:'Habitable room and every room
b"
Min 60°f 2:oOam-10:59ym
Min 64°f 11:00-6'.59am
�r-
78 F man in head
feet floor
I Cooper TM99A-UL Digital Thermometer u
take temperature readings
uiwlType(circle)
Amperage,temporary wiring,metering
Required&operational
:0
actors• Ir Note:CO detector not needed for all electric
ests Free of pests/harborage
it Bedbugs/cockroaches/rodents-evidence
h toilet
Pe r
Meer
ng season/measure 5 feet
I,5
d to
90
200,20
Bathroom
MSS
MONO
l\�
Pt
5
MINIM
I Bedroom 1
soOrn2
mat
A
i
0a
accE`i�-
c —.-- _—
)ther
il: ❑ Electric ❑ Fire_ ❑ Plumbing 0 Building 0 Other
spection report is signed and certified under the pains and penalties of perjury.
for Signature
ant or Occupant's Representative Signature Time
fection Date
OTE: `indicates that this
well-being of apeetii person(s)occupying the premises
has revealed conditions which may endanger or materially impair
re health,safety,and
Code Citation and Description of Violation
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