CROMWELL STREET < k CITY OF SALEM, MASSACHUSETTS lu
BOARD OF HEALTH
120 WASHINGTON STREET',4'"FLOOR pPubliCAeaith
TEL. (978) 741-1800 Fax(978) 745-0343
KIMBERLEY DRISCOLL lramdinna salem.com
1„\Rl2Y 12;\b(UIN,RS/I21.SI IS,CI K),C11-Ia5
MAYOR I iI,v :rl[AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#284-14
DATEISSUED: 8/25/2014
Property Located at: 2 Cromwell Street UNIT#2A
Owner/Agent: 61 Bridge Street LLC
Address: 1393 Broadway
City/Town: Saugus, MA Zip Code: 01906 24 Hour Phone:
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 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 B ARD HEALTH
4(+J• LARRY RAMDIN ~k�
HEALTH AGENT SANITARIAN
I _
® CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4°1 FLOOR PabliCHealth
Prevent,Promote.Protect.
TEL. (978)741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL lramdin@salem.com
MAYOR '" lL;�[txr x:�nn)[N,Rs/xr•.[rs,ci[o,c:P-Fs
W� HEAr.;I'IiAGENT
AUG Z I Z014
CITY OF SALEM
BOARD OF HEALTH
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
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSER ANAGER/AGENT
NO P.O.BOX
ADDRESS /31 9 Ni9O��Gt/�_ADDRESS
CITY, STATE, ZIP r'�i4l�GyS CITY, STATE,
RESIDENCE PHONE BUSINESS PHONE(24HRS) 6l7
BUSINESS PHONE ;f g y�
TOTAL NUMBER OF ROOMS: .
ROOM USE: 1. 2. 3. 4. 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 IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATUR
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:
Code Enforcement Inspector
M CITY OFSALEM, MASSACHUSE', PS
Bo ,\R ov HfE iumi
120 VUAS1-rLNG'rON S'T'REET,4""r'1,00it
llu'. (978} 741-1800
K1M13r37t1rL:Y 1>ruscor l_ f-,\x{978}745-0343
WYOR
lramdiffi a s e.(n.com
L AKRY RAMIAN,RS/ttIU IS,(:If(),
Facsimile
Transmittal
Ta: --- h ��_M "
Fax #
Date
Page(s): including this cover# C
Message:
l Y'V
Board of Health News --- — -- -- --- - _- -- --For Your Information _
OFFICE HOUR!):
Monday, Tuesday, Wednesday 8:00 AM to 4:00 PM
Thursday 8:00 AM to 7:00 PM
Friday 8:00 AM to 12:00 NOON
TRANSMISSION VERIFICATION REPORT
TIME 08/28/2014 06:08
NAME
FAX 9787450343
TEL 9787411800
SER. # 000BON341991
DATEJIME 08/28 06:07
FAX NO. /NAME 919784539150
DURATION 00: 00: 32
PAGE(S) 02
RESULT OK
MODE STANDARD
ECM
CITY of SALEM, MAssAcHUsErrs
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR PI1bi1CHC81th
Pr<vcnf.Promo,".Pmicct.
TEL. (978) 741-1800 FAx(978)745-0343
KIMBERLEY DRISCOLL Irat—njA@a,salem.Cam
MAYOR � L,\RRY RANIDiN,RS/RI:HS,GFfO,CN-FS
Hu'AM'11 AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#383-14
DATE ISSUED: 1.0/27/2014
Property Located at: 3 Cromwell Street UNIT#2
Owner/Agent: Simon Bronshteyn
Address: 38 Eastman Avenue
City/Town: Swampscott, MA Zip Code: 01907 24 Hour Phone: 978-326-4326
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
LA MDIN � -
HEALTH AGENT SANITARIAN
• CITY OF SALEM, MASSACHUSETTS
I BOARD OF HFALTI-I
120 WASI IINGTON STREET,4""FLooR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAX (978) 745-0343
MAYOR LRAMDINn.SALEM.COM
LARRY RAMDIN,RS/RGI-IS,CHO,CP-FS
HGAt,,n-I AGuwr
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
/a /�J�nFE/E: $50.00
PROPERTY LOCATED AT VI004 V1 &O JT *2- UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OOWNOE o ES?SER J r�i tin 0 n 8 rm vto�yes�Q,m vk MANAGER/AGENT
ADDRESS J� FaS( MD! d / It e ADDRESS
CITY, STATE,ZIP .1 iR A m p-Te M o/9P? CITY,STATE,ZIP U- 1/3
y J
RESIDENCE PHONE-7t/-S-63 Z �
� � BUSINESS PHONE(24HRS) J p 4—3 U— 1I 3 Gb
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. at" n/2. S Q 3. 6 P— 4. /J 2 5. 6 ✓t
6. Abtg, rJ 9 8. e � 9. 10. J
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 n
APPLICANT'S SIGNATURE �� AAM_ _ DATE
d
// ' Inspectors use onlv
Date on initial inspection:67 N Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# Check date:
Notes:
Code EnfdVement Inspector
CITY OF SALEM, MASSACHUSETTS ,
�
BOARD of HEACI'LI
120 WAST I INGTON STREET,4"FLOOR
TEL.. (978) 741-1800
KIMBERLEY DRISCOLL FAX (978) 745-0343
MAYOR LRAM131NPSALEM.COM
LARRY RAMDIN,RS/RIsHS,C1 10,CP-FS
HpACI'I-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.
w
Tenant/Lessee Owner/Lessor
3� EaSfN a 11 by S�✓Q �SC��
Address Address m ^ D,,99 7
3 C/t�� w P,� S��� M}► I �
Address on unit to be inspected
'04>3 �l
Date
Updated 5/23/11
C/ ErA
Oete 6-17-96Time 17•�ss ❑ PM
WHILEYOU WERE OUT
M
of U
Phone U
Area Code Number Extension
TELEPHONED PLEASE CALL
CALLEDTOSEEYOU WILLCALLAGAIN
WANTS TO SEE YOU URGENT
RETURNED YOUR CALL
Message
Operator
AMPAD REORDER
e EFFICIENCY® #23-e00
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Date: 06/12/96 Fan:(508)740-9705
Rockey Carvevale
90 Kernwood Avenue
Beverly, MA 01915
PROPERTY LOCATED AT 2B Cromwell Street UNIT # All
Dear Sir/Madam:
It has come to our attention, that you have rented the dwelling unit at the above
address.
It is incumbent upon you as owner(s) to contact the City of Salem Health Department
to apply for a CERTIFICATE OF FITNESS before any vacant dwelling unit is rented or
occupied, or to notify us of your intent for this unit.
Each dwelling unit must be inspected and certified by the Salem Health Department
prior to allowing occupancy in accordance with Chapter 111, Sections 127A and 127B, of
the Massachusetts General Laws, 105 CMR 400.00; 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, and in accordance with Chapter 11, Article
XIII of the City of Salem Code of Ordiances, Section 2-334, Certificate of Fitness.
There is a twenty-five (25) dollar fee payable by check, or money order to the City
of Salem Health Department. This fee is payable at the time of inspection. Inspection
will not be performed without receipt of payment.
Failure to comply with this procedure, will result in a fine of twenty (20) dollars
per day for every day that the dwelling unit is occupied without approval of the Code
Enforcement Division of the Salem Health Department.
Contact this department within 24 hours of receipt of this notice. (508) 741-1800
Monday thru Wednesday from 8:00 a.m. - 4:00 p.m. Thursday 8:00 a.m. - 7 :00 p.m. or
Friday 8:00 a.m. to noon to schedule an appointment for an inspection.
SEE ENCLOSED SECTION 105 CMR 410,354 METERING OF GAS & ELECTRICITY
Very truly yours, -
FO THE BOARD OFF,;/HEALTH REPLY TO
Joanne Scott, MPH,RS,CHO PABLO VALDEZ
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
r
�Y CERT.# 193-96
- " FEE $25.00
DATE: 04/04/96
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Fax:(508)740-9705
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 3 Cromwell. Street UNIT #: 2
OWNER/AGENT: John & Anna Fraczek
ADDRESS: 29 Buffum Street
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 744-7750
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 HEALTH DEPARTMENT AND THE UNIT MAY NOW BE RENTED AND/OR OCCUPIED.
MAXIMUM NUMBER OF OCCUPANTS, BASED ON 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
SECTION 410 .400 (B) : DWELLING UNIT (X) AND 410.400 (C) : ROOMING UNIT
MINIMUM SQUARE FOOTAGE FOR SLEEPING PURPOSES: .
NOTE: THIS APPROVAL DOES NOT CERTIFY COMPLIANCE WITH THE STATE LEAD LAW FOR
OCCUPANTS UNDER 6 YEARS OF AGE.
I
1
FOTHE BOARD OFHEALTH
JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR .
S..
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tei:(508)741-1800
APPLICATION FOR CERTIFICTE OF FITNESS Fax:(508)740-9705
IN ACCORDANCE WITH STATE SANITARY'CODE, _CHAPTER II, 105 CMR 410.000 "MINIMUM
STANDARDS OF FITNESS FOR HUMAN HABITggATION".
PROPERTY LOCATED AT 3 {yY�s2c cJGG� S/ MT # Z
OWNER/LESSER�.p _ MANAGER/AGENT
ADDRESS -2 2/ 4- �. �/ ADDRESS
CITY ! YY P.2�c. CITY
RESIDENCE PHONE el!� 7 7 G-0 BUSINESS PHONE (24 HRS.)
BUSINESS PHONE —
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 2. 3. 4 .
5, 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 21^ -- 7��y.�o� DATE �
/INSPECTORS USE ONLY
DATE OF INITIAL INSPECTION: DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE: ( DATE FEE PAID:
TYPE OF UNIT, DWELLING OTHER
NOTES:
CODE ENFORCEMENT INSPECTOR
4
CITY OF SALEM BOARD OF HEALTH
Salem,Massachusetts 01970-3928-
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Fax:(508)740-9705
RELEASE
In accordance with Massachusetts General Laws Chapter III ; Code of Massachusetts
Regulations 410.000 et. seq. ; State Sanitary Code Chapter II and Article XIII of
the City of Salem Ordinance, undersigr-ed owner/lessor and tenant/lessee of a unit
of residential property, hereby authorize the Salem Board of Health or its author—
ized 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 authorize 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.
I �
TENANT/LESSEE OWNER/LESSOR
Cy-C.? 1.4 [-lTi� y� Q 43 C x -"-e 2L1 eJ f
ADDRESS ADDRESS
_21 00 �
ADDRESS OF UNIT TO BE INSPECTED
DATE
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Date: 04/02/96 Fax:(508)740-9705
Bridge 159 Realty Trust, Lawrence Green, Trustee
159 Bridge Street
Salem, MA 01970
PROPERTY LOCATED AT 159 Bridge 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.
It is incumbent upon you as owner(s) to contact the City of Salem Health Department
to apply for a CERTIFICATE OF FITNESS before any vacant dwelling unit is rented or
occupied, or to notify us of your intent for this unit.
Each dwelling unit must be inspected and certified by the Salem Health Department
prior to allowing occupancy in accordance with Chapter 111, Sections 127A and 127B, of
the Massachusetts General Laws, 105 CMR 400.00; 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, and in accordance with Chapter 11, Article
XIII of the City of Salem Code of Ordiances, Section 2-334, Certificate of Fitness.
There is a twenty-five (25) dollar fee payable by check, or money order to the City
of Salem Health Department. This fee is payable at the time of inspection. Inspection
will not be performed without receipt of payment.
Failure to comply with this procedure, will result in a fine of twenty (20) dollars
per day for every day that the dwelling unit is occupied without approval of the Code
Enforcement Division of the Salem Health Department.
Contact this department within 24 hours of receipt of this notice. (508) 741-1800
Monday thru Wednesday from 8:00 a.m. - 4:00 p.m. Thursday 8:00 a.m. - 7 :00 p.m. or
Friday 8:00 a.m. to noon to schedule an appointment for an inspection.
SEE ENCLOSED SECTION 105 CMR 410.354 METERING OF GAS & ELECTRICITY.
Very truly yours,
FOR
THE BOARD OOF//_ HE_AL�TH- REPLY TO
Joanne Scott, MPH,RS,CHO PABLO VALDEZ
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
+L H
3 gj
1� 1F4
rnr�
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Date: 03/26/96 Fax:(508)740-9705
John & Anna Fraczek
29 Buffum Street
Salem, MA 01970
PROPERTY LOCATED AT 3 Cromwell 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.
It is incumbent upon you as owner(s) to contact the City of Salem Health Department
to apply for a CERTIFICATE OF FITNESS before any vacant dwelling unit is rented or
occupied, or to notify us of your intent for this unit.
Each dwelling unit must be inspected and certified by the Salem Health Department
prior to allowing occupancy in accordance with Chapter 111, Sections 127A and 127B, of
the Massachusetts General Laws, 105 CMR 400.00; 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, and in accordance with Chapter 11, Article
XIII of the City of Salem Code of Ordiances, Section 2-334, Certificate of Fitness.
There is a twenty-five (25) dollar fee payable by check, or money order to the City
of Salem Health Department. This fee is payable at the time of inspection. Inspection
will not be performed without receipt of payment.
Failure to comply with this procedure, will result in a fine of twenty (20) dollars
per day for every day that the dwelling unit is occupied without approval of the Code
Enforcement Division of the Salem Health Department.
Contact this department within 24 hours of receipt of this notice. (508) 741-1800
Monday thru Wednesday from 8:00 a.m. - 4:00 p.m. Thursday 8:00 a.m. - 7 :00 p.m. or
Friday 8:00 a.m. to noon to .schedule an appointment for an inspection.
SEE ENCLOSED SECTION 105 CMR 410 .354 METERING OF GAS & ELECTRICITY.
Very truly yours,
FOR THE BOARD OF HEALTH REPLY TO
J
Joanne Scott, MPH,RS,CHO PABLO VALDEZ
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
MA0ak-qCity of Salem, Massachusetts
Boardof Health
120 Washington Street, 4th Floor, Salem, Publ>ICH�81th
MA 01970 Present. Promole. Prowl.
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS,CHO
Mayor health@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE#: GHL-16-283
DATE ISSUED: 8/5/2016
Property Located at: 5 CROMWELL STREET UNIT#1
Owner/Agent: Simon Bronshteyn
Address: 38 Eastman Avenue
City/Town: Swampscott, MA Zip Code: 01907 24 Hour Phone:(781) 367-3110
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.
e
Wray
Larry Ramdin, MPH, REHS, CHO
HEALTH AGENT SANITARIAN
CITY OF SALEM, MASSACHUSETTS
• - BOARD OF HEALTH
120 WASHINGTON STREET,47'FLOOR
Ti-]-. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR LRANIDINnsALENLCONI
LARRY RAMDIN,RS/REI-IS,CHO,CP-ES
HEAj-Tj-I 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"
flet
$50.00
PROPERTY LOCATED AT ULO►1tW"�- Xf UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER S/c M Dh Q I-D n S eg tti MANAGER/AGENT
ADDRESS—,3(P jEOLEtl''IQK /tVC,
ADDRESS
7
CITY, STATE,Z>P SWantpseo-tt MAD 507 CITY,STATE,ZIP
RESIDENCE PHONE qy41 -?36/7 -31 o BUSINESS PHONE(24HRS)
BUSINESS PHONE J 7 �3) 6^\.f 3 2-6
TOTAL NUMBER OF ROOMS: J
ROOMUSE: 111'V; 11 ' 2. 8-dryyvK3.8rJ oy^ 4.8('OCr04141 5. Ekge-k
6. 7. 8. 9. 10.
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME,OF INSPECTION /
APPLICANT'S SIGNATUREDATE 7 �b
I S1nn Inspectors use only
LO Date on initial inspection: I Date of reinspection: O?/0 Y17
Date of issuance of certificate:_D$ B aIX Date fee paid: j ! I I-Il to
Type of unit: Dwelling l6 Other Check#Check date: -7 (1 o`I(0
Notes:
Cod =for 6ntInspector
CITY OF SALEM, MASSACHUSETTS
• • BOARD OF HEALTH
120 WAST IINGTON STREET,4TM FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR LRAhiQ1N(a�5A1.FM COM
LARRY RAMDIN,RS/REI-IS,CHO,CP-FS
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/out absence. Itwe 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.
f
Ten6dUssee Owner/Lessor
S(AgVtAww 9,{ ail 3,� EAt07'mcl ti 411PAyA>,�I,9 s(`vf- M,4 P19 o
Address MA 0/y V Address
S nkc V M W&Tip-- �i i ;4 � , �//l C�1� l� �/�/V
Address on unit to be inspected
7�,g�/ 6
Date'Updated 5123/11
f.
N0. !03 -7
DATE x
RECEIVED FROM- ,J in10/I (fro n Sh k v, n
f ca a nci oc�ivo DOLLARS
GecaFP of 6 {n¢ 55 - 5Gr mlJe.t1
}4
Account Total $ tU°D
Amount Paid $
c e^
B@lahce Due $ _
9
Signfature `
' f.
Inspection Of_ r C117y71 PV e41 J • IJn� (- # Date Time 7 �y0XI-M
Name Address
Owner_ S i gi o r1 `8mvi /s �-e-w n Tel. No. 7 Z I - F(C)
Type of Inspection- 0 11'ACG go- oi-/� A mQSS Inspector _ �2�whuaQ L/./.,�
1176 (l
�( ' ) Remarks and Violations are listed below: /L)� R CM /1 o /.VZ(
L'1 /4oies jr) krfehen Sr-rean . I?Poa,ir .
Sala// Xi'lchPn tvindoly p1tz�.s !�O>< Jbc-k , PnG,t,�
rr-DnI Scream door poi UyrA ierArjhf - holes !n Cpor/ruSti(
v /P s . 0,0(6c or- rwlo o O_— CJe20K .
nn ba t-hryindu1 rulc crick
AM&r W)'AAU 010&j flDf /bU< , fto2g r /n- le-
Un i l need, Q re Ono-- feu Pgp lr.s
0'r 4e made . Cai/ -kr /� to 4ASjQ06,h r
Report Received by:
S - l-w IinV-0