116 LAFAYETTE STREET ROOMING HOUSE INSPECTION OCCUPANT RELEASE FORMS 5-28-2024 f
RELEASE
In accordance with the State Sanitary Code Chapter II; Chapter 2-705 of the City of
Salem Ordinance;Mass General Laws, Chapter 140, Section 25; Mass General Laws,
Chapter 148, Section 4;-and CMR 780,115.6 the undersigned owner/lessor and
tenant/lessee of a unit of residential property, hereby authorize the Salem Board of
Health, Salem Licensing Board, Salem Fire Prevention, Salem Building Inspector and
other City departments or their 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/our 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 Health, Salem Licensing Board, Salem Fire
Prevention, Salem Building Inspector and their authorized agents from any loss or injury
sustained of whatever nature and description occasioned by my/our absence during said
inspection.
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Tenant/Lessee Owner/Lessor
/A* La fziVcthe sr 31 IIS 4-,e f .ycHes+ sQJeyq MCA
Address Address O
SALL--A AA 4 7�
31r
Address of unit to be inspected
112
Date
RELEASE
In accordance with the State Sanitary Code Chapter II; Chapter 2-705 of the City of
Salem Ordinance;Mass General Laws, Chapter 140, Section 25; Mass General Laws,
Chapter 148, Section 4; and CMR 780.115.6 the undersigned owner/lessor and
tenant/lessee of a unit of residential property, hereby authorize the Salem Board of
Health, Salem Licensing Board, Salem Fire Prevention, Salem Building Inspector and
other City departments or their 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/our 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 Health, Salem Licensing Board, Salem Fire
Prevention, Salem Building Inspector and their authorized agents from any loss or injury
sustained of whatever nature and description occasioned by my/our absence during said
inspection.
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Tenant/Lessee Owner/Lessor
J14 La-4Qve#e s-f IPU7 1 e
Address Address d �G
S�fL��tAh aP ? 70
Za-'�O.Vclqrsk
Address of unit to be inspec ed
Date
RELEASE
In accordance with the State Sanitary Code Chapter I1; Chapter 2-705 of the City of
Salem Ordinance; Mass General Laws, Chapter 140, Section 25; Mass General Laws,
Chapter 148, Section 4; and CMR 780.115.6 the undersigned owner/lessor and
tenant/lessee of a unit of residential property, hereby authorize the Salem Board of
Health, Salem Licensing Board, Salem Fire Prevention, Salem Building Inspector and
other City departments or their 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/our 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 Health, Salem Licensing Board, Salem Fire
Prevention, Salem Building Inspector and their authorized agents from any loss or injury
sustained of whatever nature and description occasioned by my/our absence during said
inspection.
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Tenant/Lessee Owner/Lessor
/I L.a�aYe s4 • /�8 Cud y,P e - e n. pn.4 aIf 6
Address �a��m, /Nn Ul970 Address
//0 - R/V 6 ?A? ee �
Address of unit to be inspected
Date
s=
RELEASE
In accordance with the State Sanitary Code Chapter 11; Chapter 2-705 of the City of
Salem Ordinance; Mass General Laws, Chapter 140, Section 25; Mass General Laws,
Chapter 148, Section 4; and CMR 780.115.6 the undersigned owner/lessor and
tenant/lessee of a unit of residential property, hereby authorize the Salem Board of
Health, Salem Licensing Board, Salem Fire Prevention, Salem Building Inspector and
other City departments or their 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/our 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 Health, Salem Licensing Board, Salem Fire
Prevention, Salem Building Inspector and their authorized agents from any loss or injury
sustained of whatever nature and description occasioned by my/our absence during said
inspection.
Tenant/Lessee Owner/Lessor
Address 8gl+e ?q f MA O!q?0 Address 0 177d
11V- 11a tq� -e#e s
Address of unit to be inspected
Date
1
RELEASE
In accordance with the State Sanitary Code Chapter II; Chapter 2-705 of the City of
Salem Ordinance; Mass General Laws, Chapter 140. Section 25; Mass General Laws,
Chapter 148, Section 4; and CMR 780.115.6 the undersigned owner/lessor and
tenant/lessee of a unit of residential property, hereby authorize the Salem Board of
Health, Salem Licensing Board, Salem Fire Prevention, Salem Building Inspector and
other City departments or their 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/our absence. I/we expressly
authorized the saine and for my/our successors and assigns hereby release and discharge
the City of Salem, Salem Board of Health, Salem Licensing Board, Salem Fire
Prevention, Salem Building Inspector and their authorized agents from any loss or injury
sustained of whatever nature and description occasioned by my/our absence during said
inspection.
I�tr 0 1). '"�-KC'�''r
Tenant/Lessee Owner/Lessor
1X L4AaJ4CA A¢ c3� �B' s MA
Address Address c! 70'
//G Jal 07 Z c ve,#Cd
Address of unit to be.inspected
Date