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33-35 Oakland Street Certificate of Fitness Application 2-3-2020
A CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 98 WASHINGTON STREET,3RD FLOOR PubHc.•Hean S AI,F,M,MA 01970 Prevent.Promote.Protect. TEL. (978) 741-1800 K VE3ERLEY DRISCOLL healib@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 2 PROPERTY LOCATED AT _ � JCA-IeLJ g+fyce ��(e1T1 UNIT# J 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_C�,_ OWNER/LESSOR_, lc41t Ja MANAGER/AGENT NO P.O.BOX ADDRESS le S �' t,� } 2 ADDRESS CITY, STATE,ZIP f �" " / CITY, STATE,ZIP 00' RESIDENCE PHONE_ CELL PHONE(24HRS) q15, S5e's EMAIL �e�,+ �Pl A/d,(A S ©('e o '��ci��. C t7r'^ TOTAL NUMBER OF ROOMS: 3 ROOM USE: 1. 2. 3. 4. _ 5. Bedroom#1 ft2 Bedroom#2 ftZ Bedroom#3 ftz Bedroom#4 ft2 THERE IS A FIFTY($50)DOLLAR FEE,PAYABL BY CHECK OR MONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS PAYABLE AT E TIME OF INSPECTION APPLICANT'S SIGNATURE e� DATE Inspectors use only Date on initial inspection: a oao Date of reinspectio Date of issuance of certificate:. Date fee paid: Type of unit: Dwellin Other Check# a Check date: Notes: r- Code Enforcement Inspector '� 0@ CITY OF SALEM, MASSACHUSETTS BOARD OF HE ALTH 98 W ASHINGTON STREET,3RD FLOOR SALEM,MA 01970 �ubhCHealth Present.Promote.Protect. KIMBERLEYDRISCOLL TEL. (978) 741-1800 MAYOR health salem.com DAWD GREENBAUM 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/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 l r � I�i�1`�. �I . 3 Date C�� Time Inspection af �� Name Address � p Y Owner,_ 1 VA r- A C`e J Y�`l'�i�' _ Tel. No. Type of Inspection 1�' r�J;�te T_( �11.tJ Inspector , Lf ( " ) Remarks and Violations are listed below: , I C 2—� 1 V 'Q. 76 C�O f)Clu Z42 d OW d 1 0- t r •� 1, Y lie 0 - 1 dap v �4- -,u bcA—G" V f . I n t l I r ��A u�W be q(�2/P io _P idc) lack y i Ijpr use , r b4chqo � r,9 rA ( Z:XAZ+ff. C62MJt�� ( L� c :yeri4A�4 -&46/6-tir, r F Report Received by: