260 Apt 3D MRVP Report 1999 BCARD OF HEALTH oce-t1"4-
CITY OF NORTHAMPTON 0%•,.r.'-�°�
MEMBERS
�� JOHN T.JOYCE,Chairman MASSACHUSETTS 01060 7144,.�,Fill"� !
ANNE BURES, M.D. 1�e �'�
•�fy_•�j,.�
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
“lack,n cez,1 dlblc, �eec S
Name of Property Owner: \,t\c&c. AS3c<<.�,n,eo-.* (as56c.c, S Date: (9��
Address of Property Owner: Gecar waS Tel: Z/Z3 -,6-3 , 320
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(1) I herewith request a Housing Code Inspection and Certification of Fitness for Humar
Habitation for the following ( I ) apartment(s). (Give the total number of apartments to bE
inspected)
(2) Was dwelling Constructed 1l ., - _
Prior to 1978? Yes Er-----No o ' 'ignature of Owner
(3) Street Address; a6O c \C - S\(eek . k2edS , nn f� ice%� U•40/0
604,1-/QCt; C . ,,z,gbz ? ep,
(A) Apartment #: 3D Occupant's Name & Phone#:
Children under six(6)years old Yes No ❑ iq t1�1 , \ioate.5
(B) 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 0 No ❑
(D) Apartment #: Occupant's Name& Phone#:
Children under six(6)years old Yes 0 No ❑
(E) Apartment#: Occupant's Name&Phone#:
Children under six(6)years old Yes ❑ No 0
(If necessary,attach additional sheets to this application If more apartments are to be listed.)
(4) Enclosed is a check for $ �� for 1 inspections. ( @ $750° per apartment. )
(5) NOTE; If the dwelling(s) to inspected were constructed prior to 1978 and any children under the
i/ ip age of six (6) years reside there, you MUST have a Licensed Lead Paint Inspector
IA , certify, in writing, that the property is in compliance with the State Lead Paint Laws —
8?f b/ 760 CMR 49.04 (13). A Copy of this Lead Paint Certific. -- • . - - - - _,.__.._ •
�,�` with the Board of Health prior to issuance of the MRVP C: i�t[ nI e u ell E
(6) Return this application to: Northampton Board of Health I
1'
I 'I JUN I 0 1999 i r)1
City Hall, 210 Main Street }. r
Northampton, MA 01060 'A.L.a,.-_.--
MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTON