MOONEY ROAD MOONRY ROAD
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CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
w 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 CERT.# 316-02
FEE $25.00
TEL. 978-741-1800 DATE: 06/13/2002
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 6 Mooney Road UNIT #:
OWNER/AGENT: Leo Pereira
ADDRESS: 2 Olivia Lane
CITY/TOWN: Kensington, NH ZIP CODE: 03833 24 HOUR PHONE: 532-5717
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, BASED ON 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
SECTION 410.400 (B) : DWELLING UNIT (X) AND 410 .400 (C) : ROOMING UNIT
MINIMUM SQUARE FOOTAGE FOR SLEEPING PURPOSES: .
NOTE: THIS APPROVAL DOES NOT CERTIFY COMPLIANCE WITH THE STATE LEAD LAW FOR
OCCUPANTS UNDER 6 YEARS OF AGE. FOR MORE INFORMATION CALL 978-741-1800.
FOR THE BOARD OF HEALTH
l JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT E E FOR tMENT I SPECTOR
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CITY OF SALEM, MASSACHUSETTS
.;BOARD OF HEALTH..
3 � x. 120 WASHINGTON STREET, 4TH FLOOR
`a SALEM, MA 01970
TEL. 978-741-1800 ,
FAx 978-745-0343
STANLEY LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO -
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 LG mmn��_ UNIT
IS THIS UNIT DESIG
NATED AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER ra. MANAGER/AGENT
No P.O. Box No P.O. Box
ADDRESS �IQ �OL ADDRESS
CITY P.ns f n a-}�t� �' 02)' ITY
RESIDENCE PHONE — .- BUSINESS PHONE (24 HRS.) z_'61 I
BUSINESS PHONE _
TOTAL NUMBER OF ROOMS:___
ROOM USE: 1. K;" 2. bQ 4L 3. Ltt 4. aU n -yG6k
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
INSPECTORS USE ONLY
DATE OF INITIAL INSPECTION doAW0 e 2 DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATEG11JA0.2 DATE FEE PAID:
TYPE OF UNIT: DWELLING ✓OTHER_ CHECK a y// _CHECK DATE
NOTES:
C E FO ?MENT CTOR 9/28/98