73 HARBOR STREET ROOMING HOUSE INSPECTION OCCUPANT RELEASE FORMS 4-17-2024 S A IT-1�rl,.��t.� f�1 Q�/t� Prtrmt_Proranta.Psuteet.
Trr..�?�3'�f-f S�
h�f 1iBLT:I. D�tiSC I L health;,saknixom D.1t�{�;GR3:6 ti K ti �f
_- Hl_AIAii.fit.v.xi
Release
.accordance with Massachwetts General Laws Chapter 1 11;Code of MassachuseW Regulations 410.0 et. Seq.
State unitary Code Chapter 11 and Article XM of the City of Salem Ordinance,undersigned owner/lessor and
tenant/lessee of a=it of residential property,hereby authorize the Sale in bard of Health or its authorized age to
%rasped 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 my/our absence,I/we expressly authorized the same and for
any/our successors and assigns hereby release and discharge the City of Saleffi,Sateen Board of Health and its
authorized agents from any loss or injury sustained of whatever natme and description occasioned by my/our absence
during said inspection.
I'enantll..essee €3wnerll.essor
A s Address
Address?bivanit'�-t—o be inspected
to I
1. rv . s f
CITY OF SALEM
0.
31M,FLO,
SALF,'NI2.NIA 01970 Prennt.ProwaW FMInt.
TF,J-(979)7/41-1800
IKLMBERLEY DRISCOULhe�ith�salenixom DAVID GREIN"BAtAf
HvAIA i i A,.'
Release
in accordance with Masswbusetts General,Laws Chapter I 11;Code of Massach:usefts Regulations 410.000 et.Seq.
State Sanitary code chapter 11 and Article XE of the City of Salem Ordinance,undersigned owner/tenor and
tenmMence,of a unit of residential property,hereby authorize the Salem Board of Health or its authorized agents to
inspecA the residence identified below in accordance with the aformmAwned statutes,regulations and ordinances.
in the event it is necessary that said inspection be done in my/our absfflcet Ywe expressly authorized the same and tor
my/our successors and assigns hereby release and discharge the City of Salem,Salem Board of Health and its
auftrized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
Owneraiessor
5 6-5
SCA)e Y-NA
As Address
Address of unit to be'
C
C
C/
CITY OF S.MEN.-I, AL S-SACHUSETFS
riNC-r -,Z -RF 0(IR 98 W-,�,s% , (,), Sri -M,31L L
SALE'z - A, 01970
KIMBE RLEY DRISCOUL TF.T- (9-78)7,41-1800
health sglenixom DwiD GRiI-.,I\-,B-v w
in accordance with Massachusetts General Laws Chapter 111;Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter H and Article XM of the City of Salem Ordinance,undersigned ownerilessor and
tenanVIessee,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 ordimmm.
0,
in the event it is necessary that said inspection be done in myiour absence,Iiwe expressly authorized the sane aTys f
my/ow 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 wbatever nature and description occasioned by my/our absence
during said inspection.
Ra,
T see Owner/Lessor
k f C'Lsk 5;'I\ /117
66A
It;Z?
es,
Address
(Ij
o oi
unit to be ins
Pat loctc,k- oc� V-,
��
Dow- S� �nto
CI:C E 01 yq C-1 9 C/
CITY OF S.MEN-1, AL-�,SSACHUSETFFS
1"Loc I.-, pubucHeakh
-A—T_MA C11970 Keftal-FMUWLe-
T PT- (978) 741-1800
1JAIMLLEY DRISCOUL cam
MAYOR D.w1DGR1 1j-.',N,;8-\t'Ni
H1,'A1:1 i i
in acconlancc.With Massachusetts General L4W9 Chapter I 11;Code afros WITUSCM Regulations 410.000,et.&:q.
State Sanitary Code Chapter 11 and Article XUI of the City of Salem Ordinance,undersigned owner/lessor and
tenant4essee 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 OraMM.
In the event it is necessary that said inspection be done in myjour absence,I/We expressly authorized the same and for
my/our successors and assigns hereby release and discharge the,City of Salem.,Salem Board of Heath and its
authonzed agents from any loss or injury sustained of whatever nature and description OcCW0npd by mv/,Our absence
Juring said inspection.
Li
Owner/Lessor
bL)A
Add9s Address
Address of unit to be inspected
Date
o K/7
rp
CiTy OF S.IUEN-1, K�SSACHUSEITS
31m.FLooR
111970 Pnvent.Pxomge.PMI=C.
TRi (978)741-1800
KIMBERLEY DRISCOUL
health sake-Lcoin DAViD GREINBMAt
NI-AyoR HEA 1:111
in accordance with Massachusetts General Laws Chapter I 11;Code of Massachusetts Regulations 410.000 et. Siaq.;
State Sanitary Code Chapter II and Article XIR 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 my/bur absence,TVWe expressly authorized the same W10-to-
gay/our successors and assigns hereby release and discharge the City of Salem Salem Board of Health and its
authorized agents from any Im or mM sustained of whatever nature and description occasioned by my/our absence,
during said inspection.
z
Owners cssor
A"s Address
CAPI
Addressi un
it to be hapected
o '-n-
DEC nle
QTY OF S.IUMNI, I\L1SSACHUSEITS
-"t i P-mr,Uun FLOo.Tt
Tm- (9718)741-1800
KEMBE,RLEY DRISCOLL health salen-Lcom D.wn)GREENIBAU'M
MAYOR H i'A 1:111 1
in amordanm with Massachusetts General Laws Chapter 111;Code of Mawachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 and Article XM of the City of Salem Ordinance,undersigned ownerfiessor and
tensnVIessee 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 ordinanm.
In the event it is necessary that said inspection be done in my/bur absence,Ywe exPressly authorized the same and for
mytour 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
during said inspection.
1' roe ae
OwnerlLessor
, ) ,
Address �XJ Address
r
Address of-unit to be i�ispceted
Date I;E-to X V-1
0 K
ciTY oF s,�LEm, Atss,, .cHL-,L-,rrs
-97IR-PIET,3RD,FLOOR
SALF-17NI-MA 111970
rRi (071 8)7,41-I=200
NIBERLEYDRISCOUL health, sakn-s-corm D.wn)
Hi,A 1:111
Release
in accordance with Massachwem Generai Laws Chapter I 11;Code of Massachusetts Regulations 410.000 at. Sep.
State Sanitary Code Chapter I[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 Haft or its authorized Agents to
inspeo the residence identified below in accordance with the aforementioned statutes,regulations and ordinanm.
.. I
in the event it is necessary that said inspection he done in myiour absence,TVwe expressly authorized the same and fior
my/our successors and assigns hereby release and discharge the City of Mem,Salem Board of Health and its
wffionzed agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said'inspection.
see Ownergcssor
66A
AdJ9s Address
Address Wi as to be inspectea
V,
K
IL/
UEN
9 W tt�iJ i.:11L{'•; t.1.i-Lt1''f • ..
`SA1.F'NT,.Ml i 019770 Prerrnt.P-nwt.Protect.
,KUNIBERLEY 1 ILCOL I bealtll t'saleinxom 1JAV n)GRET'N'BA Af
MAYOR
Release
in accordance with Massachwetts General Lbws Chapter 111;Code ofMassachusetts regulations 410.000 et.Secs. ;
State Sanitary Code Chapter II and Article MR 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 myiour absence,l]Vwe expressly authorized the same and for
mytour successors and assigns hereby release and discharge the City of Salem,Salem Board of Health and its
authorized agents from any' s or injury sustained of whatever nature and description occasioned by my/our absence
during said moat.
Penant/Lessee Owner/Lessor
�-'0
Ad&ss Address
Address"Dfunit to be' ed
Date V,
DEC\0E CJ1I '�, ` gy