OLIVER STREET OLIVER STREET
b
0
a
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
08/05/2002
Judith Doering
18 Mt. Vernon Street Apt. 1
Boston, MA 02108
PROPERTY LOCATED AT 2 Oliver Street UNIT # House
Dear Sir/Madam:
It has come to our attention, that you may be considering renting a dwelling unit
at the above address.
In accordance with Chapter 11, Article XIII of the City of Salem Code of
Ordinances, Section 2-334,titled "Certificate of Fitness, " each dwelling unit must be
inspected and certified prior to allowing occupancy. The inspection will be conducted
in accordance with 105 CMR; State Sanitary Code, Chapter I: General Administrative
Procedures and 1!05 CMR 410.000; State Sanitary Code, Chapter II: Minimum Standards of
Fitness for Human Habitation.
Please notify us if you do not intend to rent the unit.
Please contact this department within 24 hours of receipt of this notice at
978-741-1800, to schedule an appointment for an inspection. Our office hours are Monday
thru Wednesday from 8 :00 a.m. - 4 :00 p.m. Thursday 8:00 a.m. - 7:00 p.m. and Friday 8:00
a.m. - 4 :00 p.m.
Failure to comply with this procedure, may result in a fine of Twenty (20) dollars
per day for every day that the dwelling unit is occupied without a Certificate of
Fitness.
A $25.00 check payable to the City of Salem is required for each unit inspected at the
time of inspection.
A property owner is required to pay gas and electricity for residential tenants if there
is not a written letting agreement stating the tenant is responsible for those
utilities and if the meter(s) records electricity and gas use which is not used
exclusively by that tenant. The Department of Public Utilities has billed property
owners for their tenants' entire utility bills retroactive to the date of initial
occupancy in cases in which cross-metering has been proven to exist.
THE BOARD HE TH REPLY TO
IR
anne Scott, MPH,RS,CHO PABLO VALDEZ
Health Agent CODE ENFORCEMENT INSPECTOR
caxn CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
ro m 120 WASHINGTON STREET, 4TH FLOOR
� CERT.# 359-02
SALEM, MA 01970
FEE $25 .00
qel� TEL. 978-741-1800
Fax 978-745-0343 DATE: 07/15/2002
-
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 4 Oliver Street UNIT #: 1
OWNER/AGENT: Kathleen Ward -
ADDRESS: 26 Winter Street
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 744-2320
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: .
1 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 I�
j JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
d
3
u CITY OF SALEM, MASSACHUSETTS
'Ng BOARD OF HEALTH
w 120 WASHINGTON STREET, 4TH FLOOR
+ SALEM, MA 01970 ✓ /
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, 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 FITNES§ FOR HUMAN HABITATION".
PROPERTY LOCATED AT ��/�f�f^ C�� UNIT#�
IS THIS UNIT DESIGNATED AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER� � _MANAGER/AGENT
No P.O. Box No P.O. Box
ADDRESS ��J� ADDRESS
CITY CITY
p� I
RESIDENCE PHONEq// 7yy— 70VBUSINESS PHONE (24 HRS.) 7�
BUSINESS PHONE_
TOTAL NUMBER OF ROOMS:_
ROOM USE: 1. K,k)" 2. _3./
5. _6. 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- ✓ � F�i�9�( _DATEC� �D7�
INSPECTORS USE ONLY
DATE OF INITIAL INSPECTION DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE: DATE FEE PAID:
TYPE OF UNIT: DWELLING OTHER_ CHECK# 17 CHECK DATE
NOTES:
CODE ENFORCEMENT INSPECTOR 9/28/98
t
ca CITY OF SALEM, MASSACHUSETTS
✓ �� BOARD OF HEALTH -
• 3 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO -
MAYOR HEALTH 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 Cit; of Salem Ordinance, undersigned owner/lessor and tenant/lessee of a unit
of residential property, hereby authorize the Salem Board of Health or its author—
ized agents to inspect the residence identified below in accordance with the
aforementioned statutes, regulations and ordinances.
L. the event it is necessary that said inspection be done in my/our absence, 1/we
expressly authorize 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 loss or injury sustained of whatever nature and description occasioned
by my/our absence during said inspection.
TENANT/LESSEE OWN R/i. SSOR —.
ADDPiESS --- ---- --- ADDRESS
ADDRESS
UNIT To INSPECTED
Q / �DOZ
SAT
CITY OF SALEM, MASSACHUSETTS
� BOARD OF HEALTH
120 WASHINGTON STREET,4"FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR 7sco'rr_SALEM.COM
JOANNE SCOTT,
HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#355-08
DATE ISSUED: 8/6/2008
Property Located at: 9 Oliver Street UNIT# 1
Owner/Agent: Donald Moore
Address: 155 Fort Avenue
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: 745-1893
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.
F R THE BOARD O HEALTH
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT CO ENFORCE�NT INSPECTOR
CITY OF SALEM, MASSACHUSETTS
j' BOARD OF HEALTH
120 WASHINGTON STREET,C FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYORT-
lai1 `^ i(� -. yy
Q,kd tscO�r(rilSALEM.COM
JOANNE SCOTT, i V 1
HEALTH AGENT yl�S I
GI�. u
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 .2 UNIT#
IS THIS TINIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER //&L,e�� O�/^' MANAGER/AGENT
NO P.O. BOX
ADDRESS ADDRESS
CITY, STATE,Zlp—,C/� CITY, STATE,ZIP
RESIDENCE PHONE 7S— '2115— /9 f y j BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 2. 3. ft 4. 5. /y-
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 PAY LE AT T/HE�TIME OF INSPECTION
APPLICANT'S SIGNATURE �lf, DATE
a Inspectors use only
Date on initial inspection: O &10,3 Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check#_Check date:
Notes:
Cb- e nforcement Inspector
? CITY OF SALEM, MASSACHUSETTS
rr
BOARD OP H]idLTH
120 WASHINGTON STREET,4...FLOOR PublicHeaI'th
'FLL. (978) 741-1800 F.\x (978) 745-0343
IaM131;R1:J3Y DR1SC01:,1, IrantdinCasalem.cotn
- l..naav IUvroIDIN,Rs/Rti:ns,cl io,ch-rs
WYOR
HIT.;\I:I'll i�C:7I3;N'I'
i
I
CERTIFICATE OF FITNESS
CERTIFICATE#324-12
DATE ISSUED: 8/15/2012
Property Located at: 9 Oliver Street UNIT#2
Owner/Agent: Donald Moore
Address: 155 Fort Avenue
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone: '745-1893
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.
FfaR47nL
/4J 1.
LARRY RAMDIN
HEALTH AGENT SANITARIA
Is
CITY OF SALEM, MASSACHUSETTS U ,
BOARD OF HEALTH f
120 WASHINGTON STREET,4"'FLOOR >EblacYieallth
Prevent.I'mmme.Pmtea.
TEL. (978)741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL Iralndin@salem.com
LrVCRY RrAMI)IN,RS/Rk:;HS,CI JO,CP-FS
MAYOR
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 UNIT#
IS THIS INNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSERMANAGER/AGENT
NO P.O. BOX
ADDRESS /(S:z ADDRESS
CITY, STATE, ZIPL/r� CITY, STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS)... 2? V ;?
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. /7 2. are D 3. 4. /�_ � 5. O
0. 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 PAY LE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE �/ �j�br/ZQ DATE
Inspectors use only
Date on initial inspection: O, Date of reinspection:
Date of issuance of certificate: Date fee paid: 6
i
Type of unit: etllling Other I Check# i, Check date:
Notes: (9� MLL 1Alfh�l 0 6CMR41 IN �el,i�
1
Co rcement Inspector
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
53 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
2/15/05
Peter Ghirardini
50 Andrew Road
Swampscott, MA 01907
PROPERTY LOCATED AT 10 Oliver Street Unit 1
Dear Sir/Madam:
It has come to our attention, that you may be considering renting a dwelling unit at the above address.
In accordance with Chapter 11,Article XIII of the City of Salem Code of Ordinances, Section 2-
334,titled "Certificate of Fitness," each dwelling unit must be inspected and certified prior to
allowing occupancy. The inspection will be conducted in accordance with 105 CMR 410.000; State
Sanitary Code, Chapter 11: Minimum Standards of Fitness for Human Habitation.
Please notify us if you do not intend to rent the unit.
Please contact this department within 24 hours of receipt of this notice at 978-741-1800, to schedule an
appointment for an inspection. Our office hours are Monday thru Wednesday from 8:00 a.m. —4:00 p.m.
Thursday 8:00 a.m. to 7:00 p.m. and Friday 8:00 a.m.— 12:00 p.m.
Failure to comply with this procedure, may result in a fine of Twenty($20.00) dollars per day for every
day that the dwelling unit is occupied without a Certificate of fitness.
A$25.00 check payable to the City of Salem is required for each unit inspected at the time of
inspection.
A property owner is required to pay gas and electricity for residential tenants if there is not a written letting
agreement stating the tenant is responsible for those utilities and if the meter(s) records electricity and
gas use which is not used exclusively by that tenant. The Department of Public Utilities has billed
property owners for their tenant's entire utility bills retroactive to the date of initial occupancy in cases in
which cross-metering has been proven to exist.
For the Board of HeReply
��Ly Reply to
nne 9 oottt�MPH, RS, CHO Pablo Valdez
Health Agent Code Enforcement Inspector
r ' S
CITY OF SALEM, MASSACHUSETTS
• BOARD OF HEALTH
t20 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
RJN MERLEY DRISCOLL FAx(978) 745-0343
MAYOR DGRCENBAUM&ALRM.COM
DAVID GR PSt3N BA UM
AC'fING HILALTt-i AGENT
CERTIFICATE OF FITNESS
CERTIFICATE #333-10
DATE ISSUED: 7/8/2010
Property Located at: 17 Oliver Street UNIT#1
Owner/Agent: Laura Mikulewicz
Address: 17 Oliver Street 2nd floor
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone:
An inspection of yourvacant 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 THXBO RDOF HEALTH
DAVID GREENBAUM
ACTING HEALTH AGENT CODE E F CEMENT INSPECTOR
' CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4T"FL r ®VED
- TEL. (978)741-1800 t
KIMBERLEY DRISCOLL FAX(978) 745-0343 13 ZW
EE
MAYOR DGRNIIAUM&MEM COM JUL
DAVID GREFNBAUM, „ k#
ACTING HEALTH AGENT
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITINTESS FOR HUM[NN F.ABITATION,"
L /FFE}E: $50.00
L
tOPERTY LOCATED AT G7 I V P1 64 UNIT# I
IS THIS UNIT DISIGNATED AS RIGHT LURF ONT OR BACK PLEASE CIRCLE ONE
NNERtLESSER Aa"-e-.9- Z MANAGER/AGENT
)P.O. BOX
2DRESS 17 OliyaiPt ST- ADDRESS, /7
TY, STATE,ZIP . A-1,g-'4CrrY, STATE,ZIPS D / T 9 0
;SIDENCEPHONE �V!7 - 409-0,'L!7 BUSINESS PHONE(24HRS)
7SINESS PHONE
)TAL NUMBER OF ROOMS:
)OM USE: 1 2 3 4 5.
6. .m 7. 8. 9. 10.
-ERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
1ARD OF HEALTH THIS FEE IS PAYABLE AT TIS TIME OF INTSPECTIO?\T
PLICANT'S SIGNATURE o�C �= !i _ DATE_7 9 / o
Inspectors use only
.e on initial inspection: Date of reinspection:
e of issuance of certificate: ::7/4/10 Date fee paid:--7, 1�
�e of unit: Dwelling {-otherCheck#_I t + � Check date:
es: �U_ A{1.,12 b0- IN (I', �' y�{1 � - fit/bOlL
e Enforc n Inspector
.eon
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH,RS, CHO 120 Washington Street
HEALTH AGENT
08/06/2001 Tel: (978)741-1800
Fax: (978)745-0343
Joan Duhaime
18 Oliver Street, #2
Salem, MA 01970
PROPERTY LOCATED AT 18 Oliver Street UNIT # 1
Dear Sir/Madam:
It has come to our attention, that you may be considering renting a dwelling unit
at the above address.
In accordance with Chapter 11, Article XIII of the City of Salem Code of
Ordinances, Section 2-334, titled "Certificate of Fitness, " each dwelling unit must be
inspected. and certified prior to allowing occupancy. The inspection will be conducted
in accordance with the State Sanitary Code, Chapter II: Minimum Standards of Fitness
for Human Habitation.
Please notify us if you do not intend to rent the unit.
Please contact this department within One Week of receipt of this notice at
978-741-1800, to schedule an appointment for an inspection. Our office hours are Monday
thru Wednesday from 8:00 a.m. - 4:00 p.m. Thursday 8:00 a.m. - 7:00 p.m. and Friday 8:00
a.m. - 4:00 p.m.
A $25.00 check payable to the City of Salem is required for each unit inspected at the
time of inspection.
A property owner is required to pay gas and electricity for residential tenants if there
is not a written letting agreement stating the tenant is responsible for those utilities
and if the meter(s) records electricity and gas use which is not used exclusively by
that tenant. The Department of Public Utilities has billed property owners for their
tenants' entire utility bills retroactive to the date of initial occupancy in cases in
which cross-metering has been proven eo exist.
FOR THE BOARD OF HEALTH REPLY TO
oanne Scott, M�0 PABLO VALDEZ
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
ujh zt
CERT.# 383-00 -
FEE -$25.00
DATE: 06/15/2000
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT, MPH, RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(978)741-1800
Fax:(978)740-9705
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 18 Oliver Street . UNIT #: 1
OWNER/AGENT: Joan Duhaime
ADDRESS.: 18 Oliver Street, #2
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 744-2285
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 NOWBERENTED AND/OR OCCUPIED.
MAXIMUM NUMBER OF OCCUPANTS, BASED ON 105 CMR 410.000: MASSACHUSETTS STATE
I 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
JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
I
.�OND�T
n M
��/MINB
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT APPLICATION FOR CERTIFICATE OF FITNESS Tel: (978)741-1800
Fax:(978)740-9705
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION".
PROPERTY LOCATED AT
IS THIS UNIT DESIGNATED AS IflGHT L gFT SON BACK PLE SE CIRCLE ON
OWNER/LESSER MANAGER/AGEI�jT
No P.O. 3 S # NADDRESS • L�
ADDRESS
CITY CITY _
RESIDENCE PHdNE �/ —BUSINESS PHONE(24 HRS.)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:__
ROOM USE: 1 2., 3,��4 —
5.
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 4�I
INSPECTORS US ON Y
DATE OF INITIAL INSPSPECTION
DATE OF ISSUANCE OF CERTIFICATE6--L,6---Q-D DATE FEE PAID:-,t'7—=—L p
TYPE OF UNIT: DWELLINt —OTHER_ CHECK# ;L i _CHECK DATE SLC-4 0
NOTES: / _
CODE ENFORCEMENT INSPECTOR 9/28198
W
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(508)741-1800
Fax:(508)740-9705
RELEASE
In accordance with Massachusetts General Laws Chapter Ill ; Code of Massachusetts
Regulations 410.000 et. seq. ; State Sanitary Code Chapter II and Article XIII of
ttie 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 author-
ized 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/our absence, !/we
expressly authorize 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
4 from any loss or injury:.sustained of .whatever. nature and description occasioned
by my/our absence during said inspection.
l
3a —T_EmNK ER/LESSOR
ADDRESS sCJ ,l, JC71 �U 4,49
ADDRESS OF UNIT T7 BE INSPECTED
DATE