BRITTANIA CIRCLE y CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343 '
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#397-04
DATE ISSUED: 08/31/2004
Property Located at: 11 Brittania Circle UNIT# 11
Owner/Agent: Breed/Webb
Address: 273 Ocean Avenue
City/Towm Marblehead, MA Zip Code: 01945 24 Hour Phone: 617-791-4171
An inspection of your vacant Dwelling/Rooming Unit at the above address has been approved
and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II"
Minimum Standards of Fitness for Human Habitation".
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of
Health and the unit may now be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever
is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
OOARD OF HEALTH
sA�
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
,11 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
00 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, IRS, CHO
MAYOR HEALTH AGENT
APPLICATION FOR CERTIFICATE OF FITNESS
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION".
PROPERTYLOCATED AT Qe�__UNIT#-I
IS THIS UNIT DESIGNATED AS RIGHT LEFTFRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER MANAGER/AGENT
No P.O. BoxNo P.O.Box
ADDRESS ADDRESS
6 CITY - AA--
CITY W6A wa.,MV&JW
—
RESIDENCE PHON�)IJV-4+,V�-BUSINESS PHONE (24HRS.)j-i
BUSINESS PHONEf
TOTAL NUMBER OF ROOMS:_I�_
ROOM USE: 1.a�2. 3._4.4.
57b4AD6_)6_'
>,1�. 7. &Af'L 151
-
THERE IS A TWENTY-FIVE($25.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE
TIME OF INSPECTION.
APPLICANTS SIGNATURE 4:� �, �t 4+ 4u� .DATE Aw�
INSPECTORS USE
DATE OF DATE OF REINSPECTION___
DATE OF ISSUANCE OF CERTIFICATES- -DATE FEE PAID: 3 0
TYPE OF UNIT: DWELLING, OTHER— CHECK
CHECK DATEZ-3-0--t)
NOTES777r
CODE ENFORCEMENT INSPECTOR 9/28/98
, ' CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
• s 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800 - -
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
RELEASE
In accordance with Massachusetts General Laws Chapter III ; Code of Massachusetts
Regulations 410.000 et. seq. ; State Sanitary Code Chapter 1I and Article XIII of
the City of. Salem Ordinance, undersigned owner/lessor and tenant/lessee of aunit
of residential property, hereby authorize the Salem Board of Health or its author-
ized agents to inspect the residence identified below in accordance with the
aforementioned statutes, regulations and ordinances.
Ia the event it is necessary that said inspection be done in my/our absence, 1/we
expressly authorize the same and for my/our successors and assigns hereby release
and discharge. the City of Salem, Salem Board of Health and its authorized agcts
frora any loss or injury sustained of whatever nature and description occasioned
by my/our absence during said inspection.
TENANT/LESSEE OWNER/LESSOR
ASEa ADDRESS y, ori
wt4A
P.DI?REB�,F NIT TO BETt\SRECTED �
i
UA'iE d