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12 Mount Vernon Street Certificate of Fitness Applications 7-30-2018 i 'k log . Prevent.Promote,Protect. KIMBFRLEY DRISCOLL + �` MAYOR I ARRY RAMDIN,Rs/RExs,cxo cP-rs HEALTH AGENT SS IN ACCORD ,R 11, 105 CMR 410:000 "MII'� C HABITATION" PROPERTY LOCATED AT � � G UNIT# �(ISS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE OWNER/LESSER /Y -� ��' MANAGER/AGENT NO P.O.BOX ADDRESS 7 OA'W n� A /tl� � ADDRESS CITY, STATE,ZIP � t©� // 011PZITY, STATE,ZIP RESIDENCE PHONE BUSINESS PHONE(24HRS) BUSINESS PHONE TOTAL NUMBER OF ROOMS: ROOM USE: 1. 2. 3. 4. 5. Bedroom#1 ft2 Bedroom#2 ft2 Bedroom#3 ft2 Bedroom#4 ft2 THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CH K O ^ONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS PAYA TI PECTION APPLICANT'S SIGNATURE �� DATES f8 spectors 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 BOARD OF HEALTH 98 WASHINGTON STREET 3RD FLOOR PublicHealth 7 Prevent.Promote.Protect. TEL. (978) 741-1800 KIMBERLEY DRISCOLL health salem.com MAYOR LARRY]LAMDIN,RS/It1�HS,CHO,CP-FS HEALTH AGEN'r 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/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 on unit to be inspected Date CITY OF SALEM, IVIASSACHUSETI"S 10 BOARD OF HEALTH 98 WASHINGTON STREET,3RD FLOOR PubHeHealth SALEM,MA 01970 Prevent.Promote.Protect. KIMBERLEY DRISCOLL TEL. (978) 741-1800 healthoa,salem.coni LiuzRY RAMDIN,RS/RI111S,CI-I0,CP-FS MAYOR H&u TH 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 FITNESSTOR HUMAN HABITATION" FEE: $50.00 PROPERTY LOCATED AT & � � �� UNIT# / IS THIS UNIT DISI NATED AS RIGHT LEFTYRONT OR BACK,PLEASE CIRCLE ONE OWNER/LESSER . � �Q MANAGER/AGENT NO P.O. BOX f�� ADDRESS � ?AW /e�; c A6 S S 01,,P�07 CITY, STATE,ZIP CITY, STATE,ZIP RESIDENCE PHONE BUSINESS PHONE(24HRS) BUSINESS PHONE TOTAL NUMBER OF ROOMS: eq ROOM USE: 1. 2. 3. 4. 5. Bedroom#1 ftZ Bedroom#2 ft2 Bedroom#3 ftZ Bedroom#4 W THERE IS A FIFTY($50)DOLLAR F ABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS AYAB E T E TIME OF INSPECTION APPLICANT'S SIGNATURE t 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: oiaCITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 98 W ASHINGTON STREET,3RD FLOOR bHCH SALEM,MA 01970 Prevent,Promote.Proteck. TEL. (978) 741-1800 KIMBERLEY DRISCOLL healthoa7salem.com LARRY R 1MDIN,RS/Iu I-IS,Clio,(,P-rS MAYOR HE-i LUM A(rEN T Code Enforcement Inspector 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. olt- Tenant/Lessee Owner/Lessor Address Address AV//- -'Al Address on unit to be inspected Date