7 MRVP Report 1999 u.J, 4J;UU 1. 0 'CV 4i4ob i lGti4 NUR[HAMP1(J . MA Z001
001
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Oat HAMP�,O
ia��'' `,AMEMBERSHEALTH CITY OF NORTHAMPTON ''�~
�♦ I`�tIj)r
MASSACHUSETTS 01060 cicr ,t'"� f'
JOHN T.JOYCE,Chairman o�� �,.
ANNE SURES.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)687-1264
APPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR
MASSACHUSETTS RENTAL VOUCHER PROGRAM
Name of Property Owner: pier (1)A&d i, Date: ,3/a it c/7
The Hampshire Property
Management Group,Inc.
Address of Property Owner: e ) Tel: (Yj.52 -7177-)
7-.o.OVA OH
Nothampton,MA 111861.086
(1) I herewith request a Housing Code Inspection and Certification of Fitness for Human
Habitation for the following ( I ) apartment(s). (Give the total number of apartments to be
inspected)
(2) Was dwelling Constructed ` V . _ .tom, .
Prior to 1978? Yes EV No O Sign'e'r= • vown-r r ,'
(3) Street Address; /7 Crn
(A) Apartment#: ' Occupant's Name& Phone#:
Children uncle-six(6)years old Yes �o 0 (,)c 'ne B rai (in c., QX��(B) Apartment #: Occupant's Ne& Phone#:
Children under six (6)years old Yes ❑ No 0
(C) Apartment#: Occupant's Name&Phone#:
Children under six(6)years old Yes 0 No 0 l
(0) .Apartment#: 1 Occupant's Name& Phone#:
Children under six (6)years old Yes 0 No 0
(E) Apartment#: Occupant's Name& Phone#:
Children under six (6)years old Yes 0 No 0 I
(if necessary,attach additional sheets to this application If more apartments are to be listed.)
(4) Enclosed is a check for$ 7,1� for _(/ ) Inspections. (a $75.0° 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 Certi ••- • . :L : E
(6) Return this application to: Northampton Board of Health D I
City Hall, 210 Main Street Il
Northampton, MA 01060 L'!; U 1999 t
MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTOlf THa;nPlora eoA HrAI