1000 Loring Avenue #B-010 Certificate of Fitness Application 4-12-2018 '9
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CITY OF SALEM, MASSACHUSETTS
_ ye BOARD OF HEALTH
120 WASHINGTON STREET,4m FLOOR
nL. (978) 741-1800
K IABERLEY DRISC0LL FAX(978) 745-0343 �2 117 a
MAYOR LRAMDIN&SALEM.COM q J D
LARRY RAMDIN,RS/REHS,CHO,CP—FS
11EALTH 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 1000 LORING AVENUE UNIT# B-010
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER LORING TOWERS APARTMENTS MANAGER/AGENT YVETTE VALERIO
NO P.O.BOX
ADDRESS 1000 LORING AVENUE ADDRESS1000 LORING AVENUE
CITY, STATE,ZIP SALEM, MA 01970 _ CITY, STATE, ZIP SALEM, MA 01970
RESIDENCE PHONE BUSINESS PHONE(24HRS)
BUSINESS PHONE 978-745-2055
TOTAL NUMBER OF ROOMS: 5
ROOM USE: I.Livin room 2.Kitchen 3.Bathroom 4.Bedroom 5.Bedroom
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 PAYABLE ATTHE TIME OF INSPECTION
APPLICANT'S SIGNATURE_ v DATE_.
Inspectors use onlr�
Date on initial inspection: * Date of reinspection:
Date of issuance of certificate: Date fee paid: —_
Type of unit: Dwelling Other Check# Check date:
Notes:
Co e or e ent Inspector
CITY OF SALEM, MASSACHUSETTS
•. . BOARD OF HEALTH120 WASHINGTON STREET,4T4 FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR LRAMDIN SALEM. OM
LARRY RAMD)IN,RS/REHS,CHO,CP-FS
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/out 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 lose or injury sustained of whatever nature and description occasioned by my/out absence
during said inspection.
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Tenant/Lessee Owner/Le or
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Address Address
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Address on unit to be inspected
Date
Updated 5/23/11