GALLOWS HILL '„ ; MCONDI$,yd City of Salem, MassachusettsLr\�\1^1/�/-J
K � LJ
Board of Health
120 Washington Street, 4th Floor, Salem, PublicHea Ith
>' � Prevent. Pmmate. Protect.
MA 01970
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-15-192
DATE ISSUED: 7/30/2015
Property Located at: 50 GALLOWS HILL ROAD UNIT#
Owner/Agent: Sabahudin Omeragic
Address: 34 Tudor Street
City/Town: Chelsea, MA Zip Code: 02150 24 Hour Phone:(781) 606-4906
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
0,--A4�
Larry Ramdin, MPH, REHS, CHO
HEALTH AGENT SANITARIAN
1
II ,
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"i FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR LIZAMDIN SAI 8M COM
LARRY RAMDIN,RS/REI IS,CI 10,CP-I'S
H I AL,n I AG LiN"I'
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:: /$50.00n
PROPERTY LOCATED AT J� Q �lrlc J,� t7 YCC�0.G �G �yv-, N�d�UNI�T#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSER�� ��� n I �L MANAGER/AGENT w e I 1
NO P.O. BOX
ADDRESS 31, r-
l �GIW _ADDRESS
CITY, STATE,ZIP (`j^el � CITY, STATE, ZIP
RESIDENCE PHONE _7& (-C)b BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: Q C 3. 4. 5.
6. 7. S. 9. 10.
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE (/)/--�-,4, 1 , y, 'C DATE
Inspectors use only
Date on initial inspection: 07/Z 3/2p] Date of reinspection:
Date of issuance of certificate: 07/2$/2-015'_ Date fee paid: 07123/20LE
Type of unit: Dwelling ✓ Other Check# Z� Check date: 07/2-21.2D -S--
Notes:
Co of cement In
,Xkctor ' S a
i
CITY OF SALEM, MASSACHUSETTS
r BOARD OF HEALTH
120 WASHINGTON STREET,4"FLOOR
TFL. (978) 741-1800
KIMBERLEY DRISCOLL FAX (978) 745-0343
MAYOR 1,RAMD1NQa SN.I-M.COM
LARRY RAn1DIN,ItS/R@;HS,CI 10,CP-FS
Hi?ALTH 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.
Tenant/Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date
Updated 523/11