89 CONGRESS STREET #210 SIGNED RELEASE FORM FOR COF Easley office
CITY OF S-ALENI,1\&'�SSACHUSE'rrs
BoiRD or HEALTH
98)XI-ksHw-GToN STREET,3RD FLooR PUNWHeafth
SALE-IM,AMA 01970 Pre°w.Promm Prat"t,
X INI I B Z-RLSY D R I S C OLL TR7,.(97,q)741-1800
health i' salemcom
TVU�YOR D.\\,ID GIU-FNIBMIM
Release
In accordance with Massachusetts General Laws Chapter I 11; Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 and Article XIH of the City of Salem Ordinance,undersigned owner/lessor and
tenant/lessee of a unit of residential property,hereby authorize the Salem Board of Health or its authorized agents to
inspect the residence identified below in accordance with the aforementioned statutes, regulations and ordinances.
In the event it is necessary that said inspection be done in mylour absence, Uwe expressly authorized the same and for
my/our successors and assigns hereby release and discharge the City of Salem,Salem Board of Health and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
dining said inspection.
4enmYLe#F-- Owner/Lessor Address Address .6
0& cg/
Address of unit to be inspected
Date