16 CHERRY STREET, #2, SIGNED TENANT RELEASE FORM FOR COF a
CITY OF SALEM, MASSACHUSETTS lu
BOARD of HEALTH
98 WASHINGTON STREET,3RD FLOOR PtCHth
SALEM,MA 01970 Prevent,Promote.Protect.
TEL. (978)741-1800
hIMBERLEY DRISCOLL health[a salem.com DAvID GREENBAUM
MAYOR HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts Regulations 410.000 et. Seq. ;
State Sanitary Code Chapter II and Article XIII 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/our absence, Uwe expressly authorized the same and for
ry/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
during said inspection.
Ten essee Own /Lessor
Ad ress Address
Address of unit to be inspected
Date