33 MRVP Report 1999 BOARD OF'HEALTH 00,orMer
MEMBERS CITY OF NORTHAMPTON --"N--4
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JOHN T.JOYCE,Chairman MASSACHUSETTS 01060 %M
ANNE SURES,M.D. �1�� ��
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)687-1264
4)ir• PPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR
MASSACHUSETTS RENTAL VOUCHER PROGRAM
Name of Property Owner: .T/� ,eEflz_T y Date: ,:?-/C- y
Address of Property Owner: 33 Cowl- 5 T Tel: 59 s-ci 2-'i
/14(Z r/MA4 7- 7--()n/ 'M 2w 6 a
(1) I herewith request a Housing Code Inspection and Certification of Fitness for Human
Habitation for the following ( J ) apartment*, (Give the total number of apartments to be
inspected)
(2) Was dwelling Constructed
Prior to 1978? Yes 3 No 0 s atur o
(3) Street Address:
(A) Apartment#: 33 3 Occupant's Name & Phone#:
Children under six(6)years old Yes 0 No fij Vgcfl,v r- ,(/Rc6 8c) C
Apartment #: Occupant's Name & Phone#:
Children under six (6)years old Yes ❑ No p
(C) Apartment#: Occupant's Name & Phone#:
Children under six (6)years old Yes ❑ No p
(D) Apartment #: Occupant's Name& Phone#:
Children under six (6)years old Yes p No p
(E) Apartment #: Occupant's Name& Phone #:
Children under six (6)years old Yes p No 0
(If necessary, attach additional sheets to this application if more apartments are to be listed.)
(4) Enclosed is a check for $ 7 A-: for / inspections. ( @ $75' per apartment. )
(5) 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.
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(6) Return this application to: Northampton Board of Healthy
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City Hall, 210 Main Street - .,m
Northampton, MA 01060 �_.
MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTON