6 Horton Street Unit #1 Certificate of Fitness 5-1-2019 City of.Salem, Massachusetts
y q Board of Health
98 Washington St, 3rd Floor Salem, MA
01970
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 David Greenbaum
Mayor health@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE#: GHL-19-245
DATE ISSUED: 5/1/2019
Property Located at: 6 HORTON STREET UNIT#1
Owner/Agent: Nicole Bouchard
Address: 20 Pierce Road
City/Town: Lynn, MA Zip Code: 24 Hour Phone:(781) 267-6121
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division 3, Section 705: Certificate of fitness of
rented dwelling unit, apartment or tenement. An inspection of your vacant Dwelling/Rooming Unit at the above address has
been approved and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II "Minimum
Standards of Fitness for Human Habitation".
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of Health and the unit may now
be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
Note: This approval does not certify compliance with the state lead law for occupants under 6 years of age.
A�11
EGagakis
David Greenbaum
HEALTH AGENT SANITARIAN
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR Public Health
SALEM,MA 01970 Prevent.Promote.Protect.
KIMBERLEY DRISCOLL TEL. (978) 741-1800
health a 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 - 1'-frr�^ ��Yf � � UNIT#��
IS THIS UNIT D SIGNAT f D AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSOR�� r Cyl� Cr r I� MANAGER/AGENT
NO P.O.BOX
ADDRESS O ADDRESS
CITY, STATE,ZIP /,4 41 tea/ /91 C( - CITY, STATE,ZIP �� C�
RESIDENCE PHONE CELL PHONE(24HRS) ,4 -
EMAIL f Y72`-
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 CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE _ DATE f/
Inspectors use onl
Date on initial inspection: ate( Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# Check date:
Notes: rlQM. '_ rll_('s 1 r P j`0 I i I
ak,-L Q��c& 1wrMevt
a
Code Enforcement Inspector
t CITY OF SALEM, MASSACHUSETTS
4=�»• BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR PnblicHealth
SALEM,MA 01970 Prevent.Promote.Protect.
TEL. (978) 741-1800
KIMBERLEY DRISCOLL health&asalem.com DAVID GREEN-BAT
MAYOR 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