89 CONGRESS STREET ROOMING HOUSE INSPECTION OCCUPANT RELEASE FORMS 4-17-2024 CITY OF S-MEM, INL1,SSACHUSETIS
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N.0 NIBE,RLEY DRISCOLL health: sAcin.com D.%ViD GIU:I-NB-VA1
MAYOR
in acwrdance with Massachusetts General Laws Chapter I 11;Code of Masuchusetts Regulations 410.000 et,Seq.;
State Sanitary Code Chapter Il and Article XM of the City of Salem Ordinance,undersigned ownerAessor and
tenant/lessee of a unit of residential property,hereby authorize the Salem Board of Healih 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 drat said inspection be done in my/our abswce,Itwe expres6ty authorized the same and tor
mytour successors and assigns hereby release and discharge the City of Salem,Salem Board of Health and its
a�thorized agents from any loss or injury sustained of whatever nature and description occasioned by my/,our absence
wring said inspection.
Owner/Lessor
Address Address
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Addms'wuii—tob—eh--m,i"e'c"te' d
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CITY OF
FID o 17 IT-IT.
S-k LEN-1,M A 01970
TRi-(978)7-41-1800
MNIBE.LE Y DMISCOLL
health,-salem.com SSA V I D
MAYOR- Hl'Am i i A,;xx-t
in accordance with Massachusetts General Laws Chapter I 11;Code of MasuchuseM Regulations 410.000et.&q.
State Sanitary Code Chapter II aad Article XIU of the City of Salem Ordinance,undersigned owner/lessor and
tenant/lessee of a unit of residential property,hereby authoriw the Salem Board of Health or its authorized agents to
inspect the readence 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 atimce,Itwe evresslY authorized the same and t--.
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 ingury sustained of whatever nature and description occasioned by ruylour absence
Jurmg said.inspection.
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PenauVLmsee Owner/Lessor
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Address Address
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Add=$of unit to be inspected
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CITY OF
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KIMBERLEY DRISCOI,i health,"salemcom
MAYOR Hi,Art t
Releau
in,amordance with Massachusetts General Laws Chapter 111;Code of lias husetts Regulations 410.000 et.Seq.;
State Sanitary Code Chapter II and Article XM of the City of Salem Crdimance,undersigned ownerltessor and
tenant/lessee of a unit of residential property,hereby authorize the Salem Board of Health or its authorized agents to
mspect the residence identified below in accordance with the aforementioned statutes,regulations and ordinances.
in the event it is necessary that said inspection be none in ray/our absence,JVwe,expressly audiorimd the same and tor
rrcytour successors and assigns hereby release and discharge the City of Salem,Salem Board of Health and its
m#horized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
Wiring said inspection.
enant/L essee Owner/Lessorbc
Z
1'1Cb 'Ss..�S 3J4a
Address Address
t
Address of unit to be inspected
10
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CITY OF S-4UEM, K�SSACHUSHITS
sAI.R-,,\,j,MA 01970
KIMBERLEYDRIScOLL TP.i-(978)7,41-1800
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M&ssachusetts General Laws ChVW 1 t 1;Code of Massachusetts Re 410. S-'B=rdance State Sanitary Code Chapter II and Article M of the Citygulatiom 000 et eq
Of Salem Ordirmop,undersigned owner/lessor and
tenant/lessee,of a unit of residential property,hereby au&0rjW the Salen,B of HeaM or it
oard
inspect the residence identified below in wwrdance wIth the aforetnentiowd authodzed agents to
statutM or
and ordinances.
in the event it is necessary that said inspection be done in r,fty/our absence,
MY/Our successors and assigns hereby release and discharge the I*e expressly author�the Same and tb,�
authorized agents frOM any loss or MjMy sustained 0 City of Salem,Salem Board Of Health and its
during said inspection. f whatever natm and desenption occasioned by my/bur ahswce
Ownerfilessor
CC ry_)
Address Ado"
Addren of ea�I- t—o be inspect;
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NI A 01970 P ub&* h
RIMBERLEY DJUS TIIT- (978)741-1,9()()I COLL
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Massachusetts Generni La"'Chapter I 11;Code ofhfassac�usgft Regulations 410.000 et eq
'wi&-r Stah��nr
tenk4j"my Code C*ft If and Mcle M of the C. of Salem ordinanc Und
ins.,jee of a unit Of redd,.flal Mperty,Eby ity e, ersi S
au&or'n the Salem Board Of Health or i and
"61-4dence identified below in accordance with the afbramendene4 gned ownernessor
Zn the event it is s,rep its au&0dWd agerb to
lkv/bur s ne'-ess"Y dIat said inspection bc done in ny Wons andordimmces,
. Ucftsom and Y/Our absen
a1donzed a*PS he* release and dis�ne the II -1/*eexpr".1 author�the s
y Cty of
agents fmM any loss or injMY s y am
Salem'Salem Board o"fealthand i e'aw for
-
said Uftained of whatever nature and desmptior, ts
Occasioned by MYIDUr absftC,.e
Addre�s GL ry )
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Ad
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Ad(hm �9
of Unit to be insPectea
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TWO 98 NXI-Mh ON-9'M'R-ET 3RD FUIt IR
SALFIN1,NIA,, (119,70
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KINIBE RLEY DRISCOLL - 978)741-1800
health,,,salemcom DAV W
MAYOR HFAi:i i i Ail-,x-va
in accordance with Massachusetts General Laws Chapter I 11;Code,of Massachusft Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 and Article X[H of the City of Salem Ordinance,undersigned owner/lessor and
tenanMessee of a unit of residential property,hereby authorize the Salem Board of Health or its authorized agents to
msped the residence identified below in accordance with the aforementioned statutes,regulations and ordinanm,
in the event it is necessary dw said inspection be done in my/our absence,Itwe expressly authorized the same and tbT
mytour successors and assigns hereby release and diodbarge the City of Salem,Salem Board of Health and its
mAorized agents from any loss or injury sustained of whatever nature and description occasioned by mylour absence,
during said inspection.
C _
Owner/Lessor
L4
IR9 aA> rIn � a il� L)
Address Address
Address to be in- We"
I—[.-
Date
C I n �_