1 DEVEREAUX AVENUE, #3 ,r .
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH -
120 WASHINGTON STREET,4"FLOOR
TEL. (978) 741-1800
I{IIvII3ERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGRr.FNBAUMQSAr..rM.com
DAVID GREENBAUNI
ACTING HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#164-10
DATE ISSUED: 4/13/2010
Property Located at: 1 Devereaux Avenue UNIT#3
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
14D
RID"
ACTING HEALTH AGENT CODE ENAZRPEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
120 WASHINGTON STREET,4`FLOOR
TEL. (978) 741-1800
ICIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DGu3ENBAUM(@SALLM.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."
FEE: $50.00
PROPERTY LOCATED AT I &g-- UNIT# 3
ISS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSEI��I�'1,IJJ� ���y�S�Iy<!� MANAGER/AGENT �Q-
NO P.O.BOX
ADDRESS3 1�2e a cfnG I��lE ADDRESS
CITY, STATE,ZIP Sy6T_(n/l - 0)9)U CITY, STATE, ZIP I
RESIDENCEPHONE9 -_4- ')L45 - 5Q0 BUSINESS PHONE (24HRS) /`6 ' �J�lJJO`Z
BUSINESS PHONE l (0JC�
TOTAL NUMBER OF ROOMS:S
ROOM USE: LJ, A- l 2. ,!)ate,. 31yy lv" ' 4. � 5. B"-A
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 SIGNATURE_ DATE
Inspectors use only
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: /5 �U Date fee paid:— q IT3110
Type of unit: Dwelling Other Check#_ Check
Notes: '111GrC m6jr J( AJ \ 6w/) �,Or 1 64-41q , . 7l/(-) davi �X 4yct�
H A-.,. —
Code Enfbr\bev6nt Inspector