4 Howard Street #12 Rooming House Inspection CITY OF SALEM MASSACHUSETTS
�� BOARD OF HEALTH 1P
120 WASHINGTON STREET 4`}'FLOOR PublicHealth
Prevent.Promote.Protect.
TEL. (978)741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin@salem.com
LARRY R:\NJDIN,RS/1tEf.-IS,CIIO,CP-FS
MAYOR HEALTH AGENT
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.
T e-na`n�V L e s s e e Owner/Lessor
y 7
Address Address
Address of unit to be inspected
Date