10 Winter Street Certificate of Fitness Application 3-12-2020 R CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR PubhcHealth
SALEM,MA 01970 pr`°`"`.p`°mot`.Prot°°`.
TEL. (978) 741-1800
KIlvIBERLEY DRISCOLL health@salem.com DAVID GREENBAUM
MAYOR HEALTH AGENT
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 a �& I/"I,�,,�Z1Z r �' �c'� UNIT#
IF THIS UNIT IS DISIGNATED AS RIGHT,LEFT,FRONT OR BACK.PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES NO
OWNER/LESSOR,,, l 1104 MANAGER/AGENT
NO P.O.BOX
ADDRESS ADDRESS
CITY, STATE, ZIP 311 0(q 10 CITY, STATE,ZIP
RESIDENCE PHONE CELL PHONE(24HRS) J _J 33' -70 1 '
EMAIL e _.._ �� � ( �-N V ,��" �'1/1�l-'• ��
TOTAL NUMBER OF ROOMS: ll/
ROOM USE: 1. IL(' t ` V) 2.O Vl 40 0M 3. d(r1'!fZt66'i1 4. D 5.
Bedroom#1 Z� ftz Bedroom#2 Z ft2 Bedroom#3 ft Bedroom#4 ftZ
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 , I
APPLICANT'S SIGNATURE DATE 3 6 of w
Inspectors use only
Date on initial inspection: Date of reinspectio :
Date of issuance of certificate:. Date fee paid: 3/'a a,
Type of unit: Dwelling Other Check# �7 r a Check date:
Notes:
Code Enforcement Inspector
4P CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR %blicHeaft
SALEM,MA 01970 Prerent.Promote.Protect.
TEL. (978) 741-1800
KIMBERLEY DRISCOLL healt m salem.com DAv GREENBAum
MAYOR HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 11 l; 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/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 and its
authorized agents from any loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
Tenant/Lessee Owner/Lessor
Address Address
Address of unit to be inspected
Date
W-v
`.a■ . yr ,� .-..+.�.�.-.�......��
1 n RESIDENTIAL RENTAL INSPECTION FORM
Property address: l n _ 2 `� u e�-, �awl 4 ,� 0 0 -1 y
Number of units at address: Does the propertv owner live at this address? YES Unit: NO
Name of property owner: J SOVI1 6-
Mailing address of property owner: /; I rlk tz, -�Wa- "- J A 16m , AA A Q 0-1y
Telephone number of property owner: 6 r f 3- ?J 3 3 -1 0 1
Unit number for all units at this address subiect to inspection by the Massachusetts Housing Finance Agency,
Metropolitan Housing Assistance Program,the Department of Housing and Urban Development-or the Salem
Housing Authority (list all applicable unit numbers at this address):
Dates within last the 12 months when the Salem Police Department responded to a call for service at this address:
V
Has there been a disorderly house citation from the Salem Police for this address within the last three years?
YES NO
Unit number for all units at this address that have had a sanitary or building code violation within the last three
years: VA U AL-
Unit number for all units at this address that are rented out for fourteen or fewer days in the last 12 months:
II .N.�
Executed by owner on this l� day of_�1 U �+ y"`' ,20 30
Signature of owner• f �g
a