LORING AVENUE (003) r
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON SfREE'r,4"'FLOOR iPtlb�iCH v£ 1
TEL. (978)741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin asalem.com
L.UifZ1'RAlII71N,R',/RI A f5,C:7I0,CP-FS'
MAYOR FII S:\l;1'I I ACf;N'I'
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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 .3.6 CoR 1 a4 AV UNIT#_L_
IS THIS UNIT DISIGnN,/ATEliAS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
GO-3-714,
OWNER/LESSER y� !7 >}� MANAGER/AGENT
NO P.O. BOR
ADDRESS 1.w b L0(L NQ rw -4a ADDRESS
_
CITY, STATE,ZIP -S r*ft/4 N9=64*n CITY, STATE,ZIP M A-S 6 ! q7Z)
RESIDENCE PHONE BUSINESS PHONE(241IRS)
BUSINESS PHONE___�'7 & � 999 -�
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 3. 4. 5,
5, 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 1S PAYAB T E TIME OF INSPECTION ii
APPLICANT'S SIGNATURE /�/ � DATE �0 130/0
ey J Inspectors use only
Date on initial inspection: l / i �� Date of reinspection:
Date of issuance of certificate: Date fee paid: /
Type of unit: Dwelling Other t Check#/, Check date: p
Notes: F Si OZ �` wlll4 C61 ne VI_&RA� e '7CCI an tIS Ivy l➢ t
�riwt.2. tip ec'�t 15r� .
Code ,n ement Inspector
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a m
u CITY OF SALEM, MASSACHUSE=S
" &)ARD of HEAI:I'H
120 WASHINGTON S'IREF.T 4"`FLOOR PtibPCI3111h
, Prevent Ymmme Pmtta
TEL. (978) 741-1800 FAX(978)745-4343
KIMBERLEY DRISCOL.L lramdinna salem.com
L.LRRY RnnaDIN,Rs/RHI Is,CI 10,(T-I'S
MAYOR Hens:rll AGItNI
CERTIFICATE OF FITNESS POLICY
1. A Certificate of Fitness inspection is required for all rental units older than 5
years, per City of Salem ordinance;
2. A Certificate of Fitness is good for 1 year or the life of the tenant,whichever is
longer;
3. A Certificate of Fitness inspection may be obtained by calling or corning into the
Health Department and requesting an appointment;
4. Appointments must be requested at least 24 hours in advance pending an open
appointment;
5. No "same day" appointments will be granted;
6. All appointments are subject to the schedule of the inspector;
7. A rental unit will be considered occupied when either the previous tenant or the
current tenant has belongings in the unit. In the case of an occupied unit, either
the tenant whose belongings are in the unit must be present at the time of
inspection, OR have signed a release statement allowing the Board of Health to
inspect the unit.
8. Please allow at least one week turnaround time for the Certificate to be issued,
especially at the end of the month;
9. A Certificate of Fitness will be granted when:
a. An inspection has been conducted by a Health Department employee
b. An application has been filled out and a check or money order has been
received
10. If you have any questions, please contact the Health Department
I
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I
1
CI'T'Y" OF SALEM, MASSACH USI M'S
BOARD OF HEm TH
120 WASHINGTON STREFr,4'"FLOOR PUttliCm1�E81th, -
TEI,. (978) 741-1800 F.kx(978) 745-0343
KIMBERLEY DRISCOLL lramdin(n salem.com
MAYOR LAItR�'R.�nn»N,ttsf RouIS,a lo,cr-Fs
HVALHI A(;VN'P
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 authorised 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.
Tenant/Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date
Updated 523/11