Custom Pools Inc. Pool Permit Application 4-30-2019 � CITY OF SALEM,
MASSACHUSETTS
BOARD OF HEALTH %blicHealth
Prevent.Promote.Pro_ect.
98 WASHINGTON STREET,3RD FLOOR
TEL.(978)741-1800
KIMBERLEY DRISCOLL health(i4salcm.com DAVlD GREENBAUM
MAYOR HEALTH AGENT
APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL
NAME OF APPLICANT t!Ltb�6m �' S 11^ . TEL#
MAILING ADDRESS
EMAIL ADDRESS K C ct r-ev,6
CERTIFIED POOL OPERATOR
Name: � �1 h C��'e�o Cert#: TEL#
DATES OF OPERATION(if not annual):
DAYS&HOURS OF OPERATION: 36,5 Af S pe-r
TYPE OF POOL
Public
Semi-Public
Special Purpose
Surface Area L� 0 sf Volume UOG gallons Bather Load
FEE: $210.00 for year-round pools V $140.00 for seasonal $40.00 Non-Profit
(Please pay total with one check payable to the City of Salem)
This permit is not transferable and must be reissued upon change of ownership.
In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 63C,Section 49a,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,
have filed all state tax returns and paid all state taxes required under the law.
Signature Date SS#or Federal Identification Number
This section for office use only
Check#1�Date Amount