6 MONROE STREET SIGNED TENANT RELEASE FORMS fa it crry O1
BOARD ol= l-1EALTI-1
98��':�SIIIrvc; rc�� Srul:i.r,�l:n Fl,c oiz Public Health
Ti-,i- (9781 711-1800
ICI.\II F•:RI.F'N DRISC;OIA,
Health d4salem.com DAVID CiR6FNBAL'M
1IAYOR Hr_1L-M 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, 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 and its
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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TenantA�ssee Owner/Lessor
Wo 04 -C9
Address Address
9 -3 /2,-
Address of unit to be inspected
Date
-Y OFSAI,EXI, MASSM-:11USF,"ITS
130ARD OF I[F.ALTH
98 11-NGTON5TRIT.T,31�1) Public Health
Tr-,.i,. (978) 741-1800
heal I.M-i)salem.cori V)AVID(-,R1-'FNBAU.N[
.\GENT
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, 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 and its
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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�-enant/Lessee Owner/Lessor
1� ftfVW-0 eS�
-
Address Address
103
Address of unit to be inspected
Date
CITY OF SAl',EN1 INIASSACHUSE-ITS
BoARD 01:HEALTI I
-
1)8 WAS I I I INJ G T0 N STR 1 7 F F,31,1) F)'oolz Public Health
1B FRI-HYDRISCOLL Tr:i- (978\ 741-1800
NfAYOR heal thr(i)salern.com DAVIDGRFENBAUM
Hi AT.-M .\GENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 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, 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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
Tenant/I see t-----'Owner/Lessor
6 O l-op- JZ
Address Address
Address of unit to be inspected
7
Date
130ARD O 1-ILALT11
98 WAS IHNGT0,\ ST1"1,"1:'r,:31un Fl, oic PublicHealth
TrL. (978j 741-1800
ILL\Il3F.F�l.l-:1'T�}:[ti(:C)L.l.,IAti'C)R heal th'%7)salem.corrl
t \11-)GRr .NBAL-M
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, 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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
1
Tena [/Ilee Owner/Lessor
Address Address
Address of unit to be inspected
�L f7 -
Date
C -1-Y0FS/u,1;,%m MASSACITUST"ITYS
1
R D 0 17 1-1 I'A LTI I
Public Health
"F1--'[- (978" 741-1800
I-,:1.\113 F R 1.F Y 1)R I S LI,
.MAYOR health cl)salem.com DAVID C7PEENBAU-NI
AGENT
Release
In accordance with Massachusetts General Laws Chapter I 11; 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, 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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
T ssee Owner/Lessor
Address Address
0
Address of unit to be inspected
n'
Date
CF FYOFSAIAE.Nf INTASSACTIUSFITI'S
BOARD o r', H
98 WASHH]NG]-'ON S'nz 1 3w) Fwoiz PublicHealth
(978) 741-1800
MAYOR heal thO).salem.com DAVID GREENBAUM
HE-m:fii AGENT
Release
In accordance with Massachusetts General Laws Chapter I 11; Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 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, 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 and its
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
� #Oyve-
Address Address
Address of unit to be inspected
Date
r�
CITY OF SALEM, MASSACHUSETTS
' BOARD OF HEALTH
•L.3.-
98 WASHINGTON STREET,3RD FLOOR PubliCHean
SALF-M,XL), 01970 r...,.,.
TEL. (978) 741-1800
IMBERLEY DRISCOLL health�7salem.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,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 and its
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 Address
�1
Address of unit to be inspected
Date
tali CI ly ol-" S m.,l.M.1 LtiIASSAC:I-IUSF?' TS 10
Bo ARD 01"HEALTH
98 � '.�SElltic;'i'c�n S'i'}:rci.'i',�RI� F1,001z
Public Health
Tr%i- (978) 741-1800
-
MAYORhealthrq)salem.corn
UAVID GREE\13ACM
HEAL-nl 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, 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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
Tenant/ essee Owner/Lessor
� Y& 4 roe
Address Address
2� o
Address of unit to be inspected
Date
(J.1 LT S f-,"J'J'S
ffl, SALFAI NNIASSA Q'I-Y
Bo.mm ol:
Public Health
Fiu,F,1' r)RISCOIJ, Ti-"T'. (978) 741-1800
MAYOR heal th(a)salem.com I)AVID GRFFNBAL"M
HE'AL-111 AGENT
Release
In accordance with Massachusetts General Laws Chapter I 11; 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, I/we expressly authorized the same and for
my/our successors an as.igns hereby release and discharge the City of Salem, Salem Board of Health and its
authorized agents f Any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said ins io .
L
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Tenaift4essl e Owner/Lessor
/-tr J /Iffor Address Address
� za�
Address of unit to be inspected
J , 17-1f
Date
CITY OF SALE'M, MASS.ACITUSE'l-l'S
BOARD OF HEALTH
TT,31zi) Fwoiz
98 WA I I I N S GTO N STR F
Public Health
Tm- (978" 741-1800
K,[Nill FAMY'Y DRI5C011, j
health(Li)salen-i.cQm DAVID GREENBAU.N4
.\4AY(-)R HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter 11 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, 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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
T nant/Lessee Owner/Lessor
Yyt"\M
Address Address
Address of unit to be inspected
/7 - 1
Date