286 Washington Street Rooming House Inspection 8-14-2019 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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T 4nant/ see Owner/Lessor
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Address Address
Address of unit to be inspected
r 9
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
aa(v Aldshlaqkrls p y
Address Address
Address of unit to be inspected
Date