1 DEVEREAUX AVENUE #2 CITY OF SALEM, MASSACHUSETTS
• • BOARD OF HEALTH
120 WASHINGTON STREET,4:"FLOOR
TEL. (978) 741-1800
K NIBERLEY DRISCOLL Fax(978) 745-0343
MAYOR DGREENBAUMnsnl,r•.M.COM
DAVID GREFNBAUM
ACTING HFALTI-I AGENT
CERTIFICATE OF FITNESS
CERTIFICATE# 165-10
DATE ISSUED: 4/13/2010
Property Located at: 1 Devereaux Avenue UNIT#2
Owner/Agent: Ellen Dubinski/Ilene Simons
Address: 3 Devereaux Avenue
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
I l�
AVID GREENBAUM
ACTING HEALTH AGENT CODE ENFO'KtdEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS /U
r • BOARD OF HEALTH
120 WASHINGTON STREET,4`FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR D(3REENBjkUM@ ALEM.COM
DAVID GREENBAUM,
ACTING 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."
bp
FEE: $50.00
PROPERTY LOCATED AT bpay eJ (-:-t?" ay-p - UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK.PLEASE CIRCLE ONE
,OWNER/LESSERa i n S m O4 MANAGER/AGENT `S �
NO P.O.BOX +i
ADDRESS 3 'L— tel ADDRESS
CITY, STATE,ZIP IyC�.-V-A/ 1'YI)A- C) 19-�6 CITY, STATE,ZIP
RESIDENCE PHONBUSINESS PHONE(24HRS) L �" Q �p
E
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: (D 11 t1 I
ROOM USE: 1. � i11l[ll0�y+ 2.h Jdd✓r 3.6: nirn m4. I.�Vi2ngvr 5.
6.T-VJ1 ,== 7. 8. 9. 1 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 PAYABLAT THE TIME OF INSPECTION /
APPLICANT'S SIGNATUREd� ` DATE "t ' ' Z6
Inspectors use only
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: /3 10 Date fee paid:
Type of unit: Dwelling Other ICI--heck# A S /Y lD
Check date: y
Notes:'_n�-Wali
Fv tu/Yl U/1 7 l cfr Ci ji� hC WG-Hf, Add- r`Gf bcll fCir
Code EnforNajent Inspector