7 MRVP Report 1999 (2) \t cC1tie
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BOARD OF HEALTH CITY OF NORTHAMPTON ,% «.;;�%.
MEMBERS i •'
MASSACHUSETTS 01060 3'%441 'r'•'i
JOHN T.JOYCE,Chairman �� ,,itt-.#
ANNE BURES,M.D. ��'.,
CYNTHIA DOURMASHKIN,R.N. `G!'_' ?"'
PETER J.McERLAIN,Health Agent
OFFICE OF THE 210 MAIN STREET
(413)587-1214 BOARD OF HEALTH NORTHAMPTON,MA01060
FAX(413)587-1264
OI
APPLICATION FOR HOUSING INSPECTION AND CERTIFICATION OF FITNESS FOR
MASSACHUSETTS\RENTAL VOUCHER PROGRAM
Name of Property Owner: �OT c 2 ‘,3\Aa L 61/4) _ Date: ) 1 ) 1 L J i
cit
Address of Property Owner: Y to M A -p L c L , $ c) S 14 r i s Tel: 581, -24 ,53L
0,.-r44-A h -v .�. A 0 1 0 & 4
(1) I herewith request a Housing Code Inspection and Certification of Fitness for Huma.
Habitation for the following ( ) ) apartment(s). (Give the total number of apartments to b
inspected)
v
(2) Was dwelling Constructed
Prior to 1978? Yes [g/' No ❑ Sign:ture of Owner
(3) Street Address: 1 . b L SJ S 6 Lc-1' K 'T-R S r
(A) Apartment #: I ( c Occupant's Name & Phone#:
Children under six (6) years old Yes 0 No / t'vQ
(B) Apartment #: Occupant's'Name� 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 ❑
(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 0 No ❑
(If necessary, attach additional sheets to this application if more apartments are to be listed.)
(4) Enclosed is a check for $ 1 J.'. o q for 1 inspections. ( @ $75' per apartment. ;
(5) NOTE: If the dwelling(s) to inspected were constructed prior to 1978 and any children under thi
age of six (6) years reside there, you MUST have a Licensed Lead Paint Inspecto
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 Certific:,.1. - .. ...14.1,,;21. - il•c
with the Board of Health prior to issuance of the MRVP M: �: �.. l• i�� -' I
l
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(6) Return this application to: Northampton Board of Health 1 NOV 16 1998 :L,
City Hall, 210 Main Street
Northampton, MA 01060 1 -_.1
NORTHAMPTON BOARD OF HEALTH
MAKE CHECKS PAYABLE to the CITY OF NORTHA • • 1