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38 MRVP Report 1999 -6 J a3—AMrp BOARD-©F HEALTH CITY OF NORTHAMPTON �;a•�`+-°" MEMBERS �,r�j.' tike +-711 MASSACHUSETTS 01060 "� ait r a, JOHN T.JOYCE,Chairman o1 �� ANNE BURES,M.D. i :YNTHIA DOURMASHKIN,R.N. TER J.McERLAIN,Health Agent OFFICE OF THE 210 MAIN STREET (413)587-12'14 BOARD OF HEALTH NORTHAMPTON,MA 01060 FAX(413)587-1264 APPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR MASSACHUSETTS RENTAL VOUCHER PROGRAM L,t,t).A VP, \te4: Date: Z "23 - `?`l ne of Property Owner: tress of Property Owner: 32 7,rv..,1w n 11 RJ . Tel: 585 -3e/9- Nor 4-4,App-o, x85 -gg19- Nor ,App-ov* MA oto('O I herewith request a Nousing Code Inspection and Certification of Fitness for Humar Habitation for the following ( I ) apartment(s). (Give the t numbe of apartments to b( inspected) Was dwelling Constructed / ^- A.1-7-1) Prior to 1978? Yes H No ❑ Signature of Owner Street Address: 38 kAwley S. klof tLA,14 O,� AA (A) Apartment #: 2.. Occupant's Name & Phone#: Children under six (6) years old Yes ❑ No V LOaA C°U 'V 535- t 16 (B) Apartment#: Occupants Name & Phone#: Children under six (6)years old Yes p No 0 (C) Apartment#: Occupant's Name& Phone#: Children under six(6)years old Yes ❑ No ❑ (D) Apartment #: Occupant's Name & Phone#: Children under six (6)years old Yes ❑ No ❑ (E) Apartment #: Occupant's Name &Phone#: Children under six(6)years old Yes o No ❑ (If necessary, attach additional sheets to this application if more apartments are to be listed.) Enclosed is a check for$ 7,5(°° for 1 inspections. ( @ $75'00 per apartment NOTE: If the dwelling(s) to inspected were constructed prior to 1978 and any children under tI age of six (6) years reside there, you MUST have a Licensed Lead Paint Inspect( 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 filE with the Board of Health prior to issuance of the MRVP Certification letter. / I) Return this application to: Northampton Board of Health O. ff 5 City Hall, 210 Main Street D Northampton, MA 01060 MAKE CHECKS PAYABLE to the CITY OF NORTHAMPTON