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7 Palmer Street Certificate of Fitness Application 5-9-2019 to q r ' CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTFI 98 W ASHINGTON STREET,3RD FLOOR PablicHwIth SALEM,MA 01970 Prevent,Promote.Protect. TEL. (978) 741-1800 KIMBERLEY DRISCOLL health@salem.com DAVID GRL`JtNBAUM MAYOR FiEALTII AGENT Application for Certificate of Fitness IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-7051- "CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT, APARTMENT OR TENEMENT— FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" FEE: $50.00 PROPERTY LOCATED AT / &-V,2se� J� UNIT# IS THIS UNIT DIISIGNATED AS RIGHT LEFT F ONT OR BAC PLEASE CIRCLE ONE OWNER/LESSOR )--�, -,�?_ G MANAGER/AGENT NO P.O.BOX ADDRESS '-'va S-1• ADDRESS CITY, STATE,ZIP SGt AA62 14 CITY, STATE,ZIP RESIDENCE PHONE 01 7�— -7y L s 13, CELL PHONE(24HRS) r- EMAIL, — r- TOTAL NUMBER OF ROOMS: (P ROOM USE: 1 / 'v 2.b�jnl ;ky flle, 4__ 5. Bedroom#1 ✓ ft2 Bedroom#2 ft2 Bedroom#3 ft2 Bedroom#4 ft2 THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS P jLEAT THE IME OF INSPECTION APPLICANT'S SIGNATURE DATE Inspectors use only_ Date on initial inspection: Date of reinspection: Date of issuance of certificate: Date fee paid: Type of unit: Dwelling Other Check# Check date: Notes: i % Code Enforcement Inspector Ran-- y(�..U(1 konc '� ttk,n,z:_ No "fan ��2' CITY OF SALEM MASSACHUSETTS BOARD OF HEALTH 10 98 WASHINGTON STREET,3RD FLOOR PublicHealth Sq1 L M'r�fV1 A1 01 970 Prevent,Promote.Protect. TCtL.L(9781) 7141-1800 KIMBERLEY DRISCOLL health@saleni.com DAvtD GREt:NBAUM MAYOR HF,\LTII ACrE?NT Application for Certificate of Fitness IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-705 "CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT, APARTMENT OR TENEMENT" FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" FEE: $50.00 PROPERTY LOCATED AT �p1 /,q UNIT#_ IS THIS UNIT DISIGNATED AS RIGHT LEF FRONT OR BACK, CIRCLE ONE lXr7r- OWNER/LESSOR y LLB- C2 MANAGER/AGENT NO P.O. BOX ADDRESS ^�Lkei �YL ADDRESS CITY, STATE, ZIP 191 q 7,9 CITY, STATE,ZIP RESIDENCE PHONE q 79 r 77Y U —S �3 CELL PHONE (24HRS) EMAIL - TOTAL NUMBER OF ROOMS: ROOM USE: l-V`h �In • 2�' ✓ I to 3.�Ge � 4. 5. J Bedroom#1 ✓ ft2 Bedroom#2 Z Bedroom#3 ✓ ft2 Bedroom#4 W THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION APPLICANT'S SIGNATURE DATE InVectors use only Date on initial inspection: Date of reinspection: Date of issuance of certificate: Date fee paid: Type of unit: Dwelling Other Check heckk#.�, � Check`d,,atte: Notes: (C� �� ' !mi Of ay" " Code Enforcement Inspector F CN '�_ = � S' � C(.� r— S DEC a -- 2olB r INSPECTION CHECKLIST:SECTION 8 HOUSING CHOICE VOUCHER PROGRAM ❑ jlllllil; Or'one Osvaldo Cintron CtiDII 0.1nitlal IAnnu- Time al ❑Special. .spy s . atmly Comp Ai F Z MA ��Af v era1'Information lilts ninor speeted RAC HoasingT.rne tY - YearBuih ink ❑ Single Family Detached .- County � to ip er 6 yrs Essex MA portent on ❑Duplex or Two Family _ `. =-.•'. (i;.--:,�-•; - � Informa on Three Family ease advised that an inspeotio r ❑' Row House or Town House s phone----�� Y~ 13 y unit has been scheduled Or ei—/ dw CK� �.�.�•� 15 M ❑ Low Rise:3,'4 Stories incl ding between the houk 6f Garden Apartment ,1+� R-9:OOAM-12:00 PM' ❑1:00 PM-4:00 PM ❑ High Rise:5 or more stories (� Please Note:You must be present to provide ❑ Manufactured Home rate - ip Q entrance to your unit or have a responsible adult ❑ le Room Occu Sin anc Q' I (age 18 or older).thereon your behalf.Failure g P Y do so will jeopardize your subsidy and result in a ❑ Independent Group Residence $25.00 fee for No Show ❑ Vass ❑ Fail ❑ Inconclusive A� Access Needed CND GRD — O Tenant Caused Fail - �— -----��—^ -- 24HonrFail NSPEC ONCUFCKLIST =YEs/rnsS F=No/FAIL 1=11NC0NCLUSIVE T=TEnratwrC.LnsEn 1.l Living Room Present - 4;• .' w - T auk G- Flral 4 .'- 1.2 .Electricity 1.3 Electrical Hazards 1.4 Security 1.5 Windows Condition,Screens;Light 1.6 Ceiling Condition 1.7 WalI Condition 1.8 Floor Condition 1.9 Lead-Based Paint Are all painted surfaces free of deteriorated paint? Not Applicable !f net,do deteriorated surfaces exceed two square W per _ mom and Wor is more than lo%of a-component? - . 1 Kitchen Area Present .2 Electricity .3 Electrieal.Hazards .4 Security .5 Windows Condition,Screens,Light - - .6 Ceiling Condition .7 Wall Condition .8 Floor Condition 9- Lead-Based Paint pre all painted surfaces free of deteriorated paint? JZ Not Applicable If no;do deeriorated surfaces exceed two square feel per and Wor is Marc than 10%of a component? i LL T-t Stove or Range w Oven ilig Fuel /.LL TT 11 TT Refrigerator .12 S' .13 pace floc Storage,Preparation,and Serving of Food rim P F 1 tUmnterr[ a�1 .. .I Bathroom Present - - - T ;, .2 Electricity .3 Electrical Hazards .4 Security .5 Windows Condition,Screens .6 Ceiling Condition U. ? Wall Condition r >E cons I 1 Room Code* Room Location Right/ enter/Left Fro t/Cen /Rear FloorUw, 2 Electricity �.3 Electrical.Hazards 4 Security V Windows Condition,Screens,lightCeiling ConditionWall Condition Floor Condition Lead-Based Paint�detenorated pat aces free of Not Applicable if not,do deteriorated surfaces exceal two square feet per room and islor.is rut 10°.6 of a component? 1 'Room Code*_Lo" Room Location Right Cent /Le Front/ ken /Rear Floor Level .2 Electricity .3 Electrical Hazards A Security Ar .5 Windows Condition,Screens,Light 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition ,9 Lead-Based Paint Are all pa€rued surfac-s free of. Not Applicable deteriorated paint? If not,do deteriorated surfaces exceed two square feet per room and istor is more than 10"/0 of a component? 4.1 Room Code*_ y Room Location Right/Center/Left Front/Center/Rea _Floor Level 4.2 Electricity 'T 4.3 Electrical Hazards 4 Security ,5 Windows Condition,Screens,Light 4.6 Ceiling Condition 4.7 Wall Condition 4.8 Floor Condition ,9 head-Based Paint Am all painted s facesfir-of IZNot Applicable deteriorated paint? If not,do deteriorated surfaces exceed two square feet per room and islor is mom than to%ofacomponent? °Room Codes:I=Bedroom or Any OtherRoom Used for Sleeping(regardless of type of room); 2=Dining Room or Dining Area; 3=Second Living Room,Family Room,Den,Play Room,TV Room;4=Entrance Hails,Corridors,Halls,Staircases; 5=Additional Bathroom; 6=Other '}' 3yr�T:Yi.ur✓,'..t 5.1 None L1 Go to Part 6 .2 Security P.3 Electrcal Hazards 6.4 Other Potentially Hazardous Fealures in these Rooms I _ npytertt- 1 Condition of Foundation }6.2 Condition of Stairs,Rails,and Porches �i3 Condition ofRoof/Guttets *.4 Condition of Exterior Surfaces T �6.5 Condition of Chimney - 6.6 Lead-Based Paint detreai�otgt din tiee of Not Applicable if not,do deteriorated surfaces exceed twenty square feet of total exterior surface area? 6.7 Manufactured Home-Tie Downs Not Applicable - .1 Adequacy of heating Equip !LL TT 7.2 Safety of Heating Equipment 1-0 7.3 Ventilation/Cooling 7.4 Water Heater %'I L ,u7.5 Approvable Water Supply 7.6 Plumbing 7.7 Sewer Connection 7.8 Unit Electricity LL 1 f T t Sri il enet.@eal#t 8slel SaFts y- __ sr' xr"x-" t a:< v ar ta,.asipprotmF P i FjS' 8.1 Access to Unit 8.2 Entry Doors 8.3 Fire Exits _ 8.4 Evidence of Infestation - 5 Garbage and Debris �� ff up��pp II��pp ppuppp ��II [, * 030002033157 * Housing Assistance Payments Contract ��C �� y U.S.De artment Housing and Urban (HAP Contract) ban Development Section 8 Tenant-Based Assistance Office ofPublic and Indian Housing Housing Choice Voucher Program Part A of the HAP Contract: Contract Information (To prepare the contract,fill out all contract information in Part A.) 1. Contents of Contract This HAP contract has three parts: Part A: Contract Information Part B: Body of Contract Part C:Tenancy Addendum 2. Tenant Wilson, Melanie C 3. Contract Unit 7 Palmer St, Unit: 3 Salem, MA 01970 4. Household The following persons may reside in the unit.Other persons may not be added to the household without prior written approval of the owner and the PHA. Wilson, Melanie C 5. Initial Lease Term The initial lease term begins on(mm/dd/yyyy): 12/4/2014 The initial lease term ends on(mm/dd/yyyy): 11/30/2015 6. Initial Rent to Owner The initial rent to owner is:$ 1020 During the initial lease term,the owner may not raise the rent to owner. 7. Initial Housing Assistance Payment The HAP contract term commences on the fast day of the initial lease terns.At the beginning temr,the amount of the housing assistance payment by the PHA to the owner is$._901 �r"r'g of the HAP contract per month. -fi-'0..RATED A1� OUNT : 4 6H.GC The amount of it monthly housing assistance payment by the PHA to the owner is subject to change during the HAP contract term in accordance with HUD requirements. form HUD-52641(09/2014)