GEDNEY COURT CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
" 99 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
" - � TEL. 978-741-1800
GMnvs FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#408-04
DATE ISSUED: 09/02/2004
Property Located at: 1 Gedney Court UNIT# 1
Owner/Agent: Jennifer& Christopher Belmore
Address: 1 Gedney Court, Apt. 2
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 508-579-2466
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.
OR THE BOARD OF HEALTH
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS �D
BOARD OF HEALTH
• i ,120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343I�
STANLEY LISOVICZ, .IR. .JOANNE SCOTT, MPH, RS, CHO i
MAYOR HEALTH AGENT
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 1&&OR-8 C C) )0 _UNIT# I
IS THIS UNIT DESIGNATED /AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
i'/ (l MANAGER/AGENT_.
OWNER/LESSERf 111 —
No P.O. Box' / No P.O.Box
ADDRESS Ii&(JY1 OUY�h&z ADDRESS_
CITY St S YY> CITY
(e,lJ
RESIDENCE PHONEY 11 tO BUSINESS PHONE (24 HRS.)_ _
BUSINESS PHONE_
TOTAL NUMBER OF ROOMS:__-�_
ROOM USE: 1.r�ur�mr2. (ODYr13. I (i4.Ki �Ghe�l
5. tU!V _. 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 DATE vi Lz) Jj
Ij
SPECTORS USE ONLY
DAT OF INIAL INSPECTION b % DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE:
G
u T,DATE FEE PAID:c #
TYPE OF UNIT: DWELL OTHER_ CHECK# 3 Vi CHECK DATE � b
NOTES:_... _.
CODE ENFORCEMENT INSPECTOR 9128/98