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COUSINS STREET t • a CITY OF SALEM, MASSACHUSETTS lu BOARD OF HEALTH 120 WASHINGTON STREET,4`"FLOOR PublicHealth TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL liame din salem.com - IJ1Rlil'1LAMllLN,RS/RHI IS,C1 10,CP-ISS MAYOR HIS:11.:fkI AGENT CERTIFICATE OF FITNESS CERTIFICATE#273-13 DATE ISSUED: 8/1/2013 Property Located at: 2 Cousins Street UNIT#1 Owner/Agent: Harry Noyes Address: 55 Chase Street City/Town: Danvers, MA Zip Code: 01923 24 Hour Phone: 978-815-0725 Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division3, 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. FOR THE BOARD OF HEALTH LAR RAMDIN 5 �vp HEALTH AGENT SANITARIAN CITY OF SALEM, MASSACHUSETTS • BOARD OF HEALTH 120 WASHINGTON STREET,C FLOOR PcMcHean Prevent Promote.Pretttt. TEL. (978)741-1800 FAX(978)745-0343 KIMBERLEY DRISCOLL Iramdinna,salem.com - MAYOR LARRY RAMDIN,ILS/REI1S,CHO,Cl'-FS HEALTH AGENT Application for Certificate of Fitness IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" FEE: $50.00 PROPERTY LOCATED AT ( � �Aco t i! +� UNIT#_Z- IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE OWNER/LESSER 44'r—t x MANAGER/AGENT NO P.O.BOX ADDRESS 00— '504-� ADDRESS CITY, STATE,ZIP :21 b iiGv 6i CITY, STATE,ZIP P%4r�L RESIDENCE PHONE QYI/ 7 fT -©7 Z 3 BUSINESS PHONE(24HRS) BUSINESS PHONE TOTAL NUMBER OF ROOMS:_ ROOM USE: 1. be-P, 2. 3. ),- tg . 5. 6. 7. 8. 9. 10. THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE ISPAY LE AT THE TIME OF INSPECTION APPLICANT'S SIGNATURE DATE Inspectors use only Date on initial inspection: I / Date of reinspection: Date of issuance of certificate: Date fee paid- Type of unit: Dwelling Other Check# Check date: Notes: O Cade rlnspector CITY OF SALEM, MASSACHUSETT'S BOARD OF HEAI_'rij 120 WASHINGTONSTREET,4°1 FLOOR TEL. (978) 741-1800 IQM13F'RLE:Y DRISCOLL F,Ng (978) 745-0343 MAYOR lramdin@salem.com LARRY IZA NIDIN,RS/RHI IS,CI 10,CI'-FS 1-Ilt.\1;1'11 AGI:.N'I' CERTIFICATE OF FITNESS CERTIFICATE#387-11 DATE ISSUED: 10/6/2011 Property Located at: 4 Cousins Street UNIT# 1 Owner/Agent: Tache Real Estate Address: 208 Derby Street City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 978-745-2004 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. FOR THE BOARD OF HEALTH �p LARR+ RAMDIN \�JI HEALTH AGENT CODE ENFORCEMENT INSPECTOR 10/0512,p11 22:28 9787450343 PAGE 01 CITY OF SALEM, MASSA.CHUSL STS BOARD OF HEAurR 120 Wt4,tit-11NGTON S'TRPHP,4"'FLOOR UL.;975}741-1800 I<IMBERLEY DRISCOLL Fr#x (973)745-0143 .MAYOR z spr.I:N.CSrM LARRYRAMDK RS/RI?PIIS,4110 HFA 1,111 Au E,N'I' Application for Certificate of Fitness IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 1,05 CMR 410.000 MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" FEE: 50.00 PROPERTY LOCATED AT _"" -eV-r-zl s 15 I L NIT# IS THIS UNIT I)ISIGNATtD AStR U LE ff FRONT OR BACK.PLEASE CIRCLE ONP, OWNERILESSER z / n mQ MANAGER!AGENT j�ZiC�/F 'R&o-r ZSRT�:_ NO P.O.BOX ADDRESS CITY,STATE,ZIt7 �m/art S Tk %�Sc3S5� _CITY,STATE 7IP RESIDENCE PHONE l✓�a BUSII<IFsSS PHONE(24HRS) BUSINESS PHONE TOTAL NUMBER OF ROOMS: 171 ROOM USE: L 4R 1 3. �B2� 4. J) 5. 6, 7. S. 9. 1.0. 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 SIGNATUREG� c`�� j JDATE G /L Ins cctors use only Date on initial inspection: _ Date of reinspection: Date of issuance of certificate: �^ Date fee paid: Type of unit: Dwelling Other Check �1� '_Chcdk date: Notes: ` Code Enforcement Inspector CITY OF SALEM9 MASSACHUSETTS �L BOARD OF HEALTH e 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 _TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 1/24/05 Thomas E. Lawlor 4 Cousins Street Salem, MA 01970 PROPERTY LOCATED AT 4 Cousins Street Unit 2 Dear Sir/Madam: It has come to our attention, that you may be considering renting a dwelling unit at the above address. In accordance with Chapter 11,Article XIII of the City of Salem Code of Ordinances, Section 2- 334, titled "Certificate of Fitness," each dwelling unit must be inspected and certified prior to allowing occupancy. The inspection will be conducted in accordance with 105 CMR 410.000; State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation. Please notify us if you do not intend to rent the unit. Please contact this department within 24 hours of receipt of this notice at 978-741-1800, to schedule an appointment for an inspection. Our office hours are Monday thru Wednesday from 8:00 a.m. —4:00 p.m. Thursday 8:00 a.m. to 7:00 p.m. and Friday 8:00 a.m. — 12:00 p.m. Failure to comply with this procedure, may result in a fine of Twenty($20.00) dollars per day for every day that the dwelling unit is occupied without a Certificate of fitness. A$25.00 check payable to the City of Salem is required for each unit inspected at the time of inspection. A property owner is required to pay gas and electricity for residential tenants if there is not a written letting agreement stating the tenant is responsible for those utilities and if the meter(s) records electricity and gas use which is not used exclusively by that tenant. The Department of Public Utilities has billed property owners for their tenant's entire utility bills retroactive to the date of initial occupancy in cases in which cross-metering has been proven to exist. For the Board of Health Reply to J Anne Scott MPH, RS, CHO Pablo Valdez Health Agent Code Enforcement Inspector CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR c SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 1/13/05 Thomas E Lawlor&Yvonne Green 4 Cousins Street Salem, MA 01970 PROPERTY LOCATED AT 4 Cousins Street Unit 3 Dear Sir/Madam: It has come to our attention,that you may be considering renting a dwelling unit at the above address. In accordance with Chapter 11, Article XIII of the City of Salem Code of Ordinances, Section 2- 334,titled "Certificate of Fitness," each dwelling unit must be inspected and certified prior to allowing occupancy. The inspection will be conducted in accordance with 105 CMR 410.000; State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation. Please notify us if you do not intend to rent the unit. Please contact this department within 24 hours of receipt of this notice at 978-741-1800, to schedule an appointment for an inspection. Our office hours are Monday thru Wednesday from 8:00 a.m. —4:00 p.m. Thursday 8:00 a.m. to 7:00 p.m. and Friday 8:00 a.m.— 12:00 p.m. Failure to comply with this procedure, may result in a fine of Twenty($20.00)dollars per day for every day that the dwelling unit is occupied without a Certificate of fitness. A$25.00 check payable to the City of Salem is required for each unit inspected at the time of inspection. A property owner is required to pay gas and electricity for residential tenants if there is not a written letting agreement stating the tenant is responsible for those utilities and if the meter(s) records electricity and gas use which is not used exclusively by that tenant. The Department of Public Utilities has billed property owners for their tenant's entire utility bills retroactive to the date of initial occupancy in cases in which cross-metering has been proven to exist. F r the Board of Heal h Reply to oanne Scott MPH, RS, CHO Pablo Valdez Health Agent Code Enforcement Inspector CITY OF SALEM, MASSACHUSETTS ' BOARD OF HEALTH 120 WASHINGTON STREET,4'"FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR DGRI r:.NIIAUM(@SAI,FSNl.(:OM DAvt )GRuuNIiAuM ACTING HI.AI;11-1 AGENT CERTIFICATE OF FITNESS CERTIFICATE#366-10 DATE ISSUED: 8/2/2010 Property Located at: 6 Cousins Street UNIT# 1 Owner/Agent: David L'heureux Address: 6 Cousins Street City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 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 ll" 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. FOR THE BOARD OF HEALTH ' ✓17 �, ) DAVID GREENBAUM ACTING HEALTH AGENT CO NFORCEWEW INSPECTOR • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"FLOOR TFL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR DGaEENBAUM&ALLM COM DAVID GREFNBAUM, ACTING HEALTH AGFNT Application for Certificate of Fitness IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION." FEE: $50.00 tOPERTY LOCATED AT CO LC)L)s/N s 91- UNIT# / IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE IWNERILESSER N v r o L` cu g ez.v MANAGER/AGENT n c. ,,A cx )P.O. BOX )DRESS Co Cc)US/n.r S T ADDRESS TY, STATE,ZIP CITY, STATE,ZIP sn� az n J :' IDENCE PHONE °J7 - �7 k - �f J 3 BUSINESS PHONE(24HRS) JSINESS PHONE )TAL NUMBER OF ROOMS: )OMUSE: 1. WC 2. 89 3. L !Z 4 D k 5 /L. 6. 7. 8. 9. 10.— [ERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM 1ARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION PLICANT'S SIGNATURE DATE S-A-2bi(9 Inspectors use only to on initial inspection: 8�af �C) Date of reinspection: :e of issuance of certificate: Date fee paid: )c of unit: Dwelling Other Check# t Check date: :es: le Enf&cement Inspector CITY OF SALEM, MASSACHUSETTS < ; BOARD OF HEALTH r 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 Kimberley Driscoll WWW.SALEM.COM Mayor JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CERTIFICATE OF FITNESS CERTIFICATE#339-07 DATE ISSUED: 7/26/2007 Property Located at: 6 Cousins Street UNIT#2 Owner/Agent: David L'heureux Address: 6 Cousins Street City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 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. FOR THE BOARD OF HEALTH JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT CODE ENFORCEMENT INSPECTOR CITY OF SALEM, MASSACHUSETTS v - BOARD OF HEALTH �`� - ` 120 WASHINGTON STREET, 4TH FLOOR " (I SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 JOANNE SCOTT, MPH, RS, CHO Kimberley Driscoll HEALTH AGENT Mayor APPLICATION FOR CERTIFICATE OF FITNESS IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION". PROPERTY LOCATED AT_C Cou rwrT ` .UNIT#_� IS THIS UNIT DESIGNATED AS RIGHT LEFT FPONT BACK PLEASE CIRCLE ONE OWNER/LESSER_A4k✓;y 2fi� _MANAGER/AGENT_ _.— No P.Q. Box No P.O. Box ADDRESS. Sf _._ ADDRESS CITY --CITY------- RESIDENCE _CITY _— --RESIDENCE PHONE-Ilk-2f-fd e/v—BUSINESS PHONE (24 HRS.) BUSINESS PHONE TOTAL NUMBER OF ROOMS:vi� _ ROOM USE: 1._6,6D _2.AEO _3. Lr v 4.__ b/i 5.�C 6. 7. 8._ THERE IS A TWENTY-FIVE($25.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE TIME OF INSPECTION. APPLICANTS SIGNATURE INSPECTORS USEONLY DATE OF INITIAL INSPECTION . 7-.DATE OF REINSPECTION___ DATE OF ISSUANCE OF CERTIFICATE:,7�;­b vDATE FEE PAID: _%�6 TYPE OF UNIT: DWELUdI -:OTHER___ CHECK #—�Z 2_2 CHECK DATE CODE ENFORCEMENT INSPECTOR 9/28/98 r� CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4t`t FLOOR It$ Prevent.Promote.Protect. TEL. (978) 741-1800 FAX(978) 745-0343 KIMBERLEY DRISCOLL ltamdinQsalem.com LARRY RADIDIN,RS/REf-[S,CI-10,CP-7-5 MAYOR HEAL 'PH AG ENT CERTIFICATE OF FITNESS CERTIFICATE#457-12 DATE ISSUED: 11/21/2012 Property Located at: 12 Cousins Street UNIT#2 Owner/Agent: Mark & Margaret Kilczewski Address: 12 Cousins Street City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 978-354-3373 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. FOR THE BOARD OF HEALTH LARRY RAMDIN HEALTH AGENT SANITARIAN CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WAR-IINGTON STREET,4".FLOOR TFL. (978) 741-1800 KTMBFRT_,EY DRISCOI,L FdX(978) 745-034.3 '� r MAYOR i.icAM1)JNa AL1%a.CQN1 1,nwt4]UNIDIN,WS/RVI 61F.;v xi i AcF.NP Application for Certificate of Fitness IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" FEE: $50.00 PROPERTY LOCATED AT 1Z C o Lt Si k S Sk UNIT# 2 IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE OWNER/LESSER MarQ He fr3A0 Klc z ec s(c MANAGER/AGENT NO P.O. BOX ADDRESS 12 C c 4 Sl h S S ADDRESS CITY, STATE,ZIP 5'a le" CITY, STATE,ZIP RESIDENCEPHONE R7� ']YS 177G BUSMSSPHONE(24HRS) Sob cIS'F 'IL113 BUSINESS PHONE TOTAL NUMBER OF ROOMS: S ROOM USE: 1. k4-A 2. 6eZ 3 Bec 4 � iy � 5 6. 7. 8. 9. 10. THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK 0 ONEY ORDER TO THE CITY OF SALEM BOARD OF HEALTH THIS FEE IS PAYABLE AT THE T 0 SPECTION APPLICANT'S SIGNATURE . DATE 12 t 12 i Inspectors use only Date on initial inspection: 1 1 Z I 1 Date of reinspection: Date of issuance of certificate: 0• " ) -11 Date fee paid: 1 i Type of unit: Dwelling I/ Other Check# 31-3 Check date: Notes: ode Enforcement Inspector 19 i nv i/ oZ1�03._ v ,co CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA O 1970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT November12, 2003 i Jeanne Higgins 14 Cousins Street Salem, MA 01970 PROPERTY LOCATED 14 Cousins Street Unit#1 It has come to our attention, that you may be considering renting a dwelling unit at the above address. In accordance with Chapter 11,Article XIII of the City of Salem Code of Ordinances, Section 2-334,titled "Certificate of Fitness,"each dwelling unit must be inspected and certified prior to allowing occupancy. The inspection will be conducted in accordance with 105 CMR; State Sanitary Code,Chapter 1: General Administrative Procedures and 105 CMR 410.000; State Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation. Please notify us if you do not intend to rent the unit. Please contact this department within 24 hours of receipt of this notice at 978-741-1800, to schedule an appointment for an inspection. Our office hours are Monday thru Wednesday from 8:00 a.m. —4:00 p.m. Thursday 8:00 a.m. —7:00 p.m. and Friday 8:00 a.m.—4:00 p.m. Failure to comply with this procedure, may result in a fine of Twenty ($20.00)dollars per day for every day that the dwelling unit is occupied without a Certificate of Fitness. A$25.00 check payable to the City of Salem is required for each unit inspected at the time of Inspection. A property owner is required to pay gas and electricity for residential tenants if there is not a written letting agreement stating the tenant is responsible for those utilities and if the meter(s) records electricity and gas use which is not used exclusively by that tenant. The Department of Public Utilities has billed property owners for their tenants"entire utility bills retroactive to the date of initial occupancy in cases in which cross-metering has been proven to exist. For a Board of Health Reply to ?dc_� Joanne Scott MPH, RS, CHO Pablo Valdez Health Agent Code Enforcement Inspector �OONDt�i� City of Salem, Massachusetts Board of Health 120 Washington Street, 4th Floor, Salem, PublicHealth MA 01970 Prevent, Promote. Protect. Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS, CHo Mayor Iramdin@salem.com Health Agent CERTIFICATE OF FITNESS CERTIFICATE#: GHL-15-307 DATE ISSUED: 9/25/2015 Property Located at: 16 COUSINS STREET UNIT#1 Owner/Agent: Jorge Barzola Address: 16 Cousins Street City/Town: Salem, MA Zip Code: 01970 24 Hour Phone:(978) 304.2525 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. FOR THE BOARD OF HEALTH Larry Ramdin, MPH, REHS, CHO HEALTH AGENT SAN ARIAN CITY OF SALEM, MASSACHUSETTS • • BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 .- KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR LRAMOM .SA1.8M.COM LARRY RAMDIN,RS/RE11S,(:HO,Cl'-FS Hl':Aj.,ni AG1sNT �14Ic7o4►J"" V GGHA t , CoW Application for Certificate of Fitness IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000 "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" r- FEE: $50.00 PROPERTY LOCATED ATJ COBS L r) S -S UNIT# IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BAC PLEASE CIRCLE ONE OWNER/LESSpEIL-�� ��Q MANAGER/AGENT ADDRESS I h �Q Sr- ADDRESS CITY, STATE,ZIP_ � ''jj CITY, STATE,ZIP_ �( w 7 t 7 RESIDENCE PHONE�� 2 a.5 ,S- BUSINESS PHONE(24HRS)- [q? %) :30q- -252-5 BUSINESS PHONE ( 9 7 9 TOTAL NUMBER OF ROOMS: S ROOM USE: 1. 2. 3 4 l5 6. 7. 8. 9 10 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 TBE /TIME OF INSPECTION APPLICANT'S SIGNATURE DATE Z V 5 Inspectors use only Date on initial inspection:CV2/ y/2nlsf Date of reinspection: Date of issuance of certiScate:0 S— Date fee paid:azo 09C Type of unit: Dwelling Other Check#9gg9 Check date:Dr{/24/2ti1r Notes: ro o in er -Raa.et'/ h B 9 DO 0. ✓ 0. fro»+ kii'�tien �'1as a. window �,,,�4h w ho� in kl,o scrceh, C*91orceXment pector a:- v e yJ CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET 4°i FLOOR PublicHealth > Prevent.Promote,Protein. TEL. (978) 741-1800 FAA(978) 745-0343 KIMBERLEY DRISCOLL lramdiii@salem.com MAYOR L�U2R1'EAMDIN,ILC/lila is,ci-10,ch-Fs HLALF[I 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/out 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 lose or injury sustained of whatever nature and description occasioned by my/out absence during said inspection. / ems, Tenant/Lessee 3ener essor J,GraLS9)m ,---T 1 DTZ AddressSALV NA-- Address 7� lfo C�Uusin S T�. 1 S�1 �M K14, 0��i�0 Address on unit to be inspected 9 22 Date Updated 523/11 -