235 Lafayette Street Certificate of Fitness Application 6-14-2021 1 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4T"FLOOR
TEL.(978)741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR LRAMDIN@SALEM.COM
LARRY RAMDIN,RS/REHS,CHO,CP-FS
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"
FEE: $50.00
PROPERTY LOCATED AT L C�� UNIT#
IS THIS UNITDISIGNATED AS GHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSER ]F 4-L- f�Pr e MANAGER/AGENT
NO P.O.BOX -mot-
ADDRESS aL+( �0.0�_ 1P� s tr ADDRESS
CITY,STATE,ZIP Vic: din "►GL C) I Q-7o CITY,STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS) t 7 -- 7 `( d 17
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. _-L ? 2. L K 4. 5.
6. 7. 8. 9. 10.
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-&YABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE — Z
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:
Code Enforcement Inspector
• CITY OF SALEM,, MASSACHUSETTS
ij I�) M -1E.ALTI)A RD()F I -I
120 W.151 IINGTON STREET, 4... 1,1,OOjZ
Trl- (978) 741-1800
KIMBE'RLEY DRISCOLL 1'.\x (978) 745-0343
MAYOR I COM
JANET DIONNE,
SENIOR SANITARIAN
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/out absence. 1/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 lose or injury sustained of whatever nature and description occasioned by my/out absence
during said inspection.
0 PA UJI f- 5-_Wrrf� (4- H
Tenant/Lessee Owner/Lessor
a65
Address Address
eitel ST3
Address on unit to I be inspected
6-1 (4
Date