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CITY OF SALEM, MASSACHUSETTS
1/ BOARD OF HEALTH
120 WASHINGTON STREET,4"" FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR DCRE;I!NI3AUM@SAI,IYMC)M
DAvID GRF.I'.NB,\um,RS
AC•P1NG HuAI..o I AGLNT
CERTIFICATE OF FITNESS
CERTIFICATE#79-11
DATE ISSUED: 3/23/2011
Property Located at: 29A Pierce Road UNIT#2
Owner/Agent: Lillian Papalegis
Address: 29 Pierce Road
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 11"
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.
FORT E BOA OF HEALTH
�/�`/�///yy� /
DAVID GREENBAUM, RS
ACTING HEALTH AGENT CODE ENFORCEMENT INSPECTOR
4 CITY OF SALEM, MASSACHUSETTS
✓ BOARD OF HEALTH
l
120 WASHINGTON STREET,4'" FLOOR �
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR DC,RE1;NBAUMgSA1.GM.COM
DAVID GREENB-Aum,RS
ACTING HFAL`n-I 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,,? �/'���� UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
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OWNERLESS MANAGER/AGENT
NOP'0'
OP.O. BOX c
ADDRESS r 4 ADDRESS
CITY, STATE,ZIl��, AM . CITY, STATE, ZIP eg//-
7�
RESIDENCEPHONEf ? y�FI!Vk BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:__
ROOM USE: 1. 2. 3. 4. 5
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 SIGNATUR4� �-tO DATEI'
Inspectors use only
Date on initial inspection: f Date of reinspection:
Date of issuance of certificate: Date fee paid: 1
Type of unit: Dwelling-----Lec her Check#_. Check date: �� I
Notes: g1tP (Gr{fin U�I7��C� fi hc� Fk�en r i� cmo j �br a�
Cc4e En orcement Inspector