PYBURN AVENUE PYBURN AVENUE
e
m
e
+ r
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4' FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR IDIONNF.nG SALEM.COM
JANI:s'I'DIONNI:S
ACTING HEA1..I1-I A(;iWI'
CERTIFICATE OF FITNESS
CERTIFICATE#439-08
DATE ISSUED: 9/2/2008
Property Located at: 6 Pyburn Avenue UNIT#House
Owner/Agent: Mary Ann Schroeder&June Michaud
Address: 71 Auburn Road
City/Town: Londonderry, NH Zip Code: 03053 24 Hour Phone: 603-432-3434
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
�OFF �HEALTH
J N T DID
ACTING HEALTH AGENT CODE 1EZOR1dt1AEN7NZP?CTOR
--------
����S G� 1` S1 '7l 1 V
)'� Irf�� �,J�U�. � G�Fc�.� _
�1 ���,A.,�r, h1Q.��1��
�\�
• CITY OF SALEM, MASSACHUSETTS q.9�
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR Isco rr e sAMM.COM
JOANNE SCOTT,
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--C
� �YIJ U 111 1�11/2y7 U e- UNIT#
�y�1 IS THIS UNIT D IG��N)JATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER/i4tJt)n Sc1�oe,1e)- %Ne //_c4AANAGER/AGENT
NO P.O. BOXnn
ADDRESS 7/ AL)i Oen .ADV ADDRESS
CITY, STATE, ZIPGOnAg'ell 4W a2i07S3 CITY, STATE,ZIP
RESIDENCEPHONEZoO 792-' 7YSY BUSINESSPHONE(24HRS) /n 03V'?1-2 V.?,�l
BUSINESS PHONE
TOTAL NUMBER OF/ROOMS: Q p p
ROOM USE: 1. � 7( ��°� 2. �iy 6.. 3. g 4L 4. '0 e- 5.
6. 7. 8. 9. 10.
TI3ERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE n��Yl,Jrtl/' C�c� DATE ? O
Inspectors use only
Date on initial inspection: Z-O$ Date of reinspection:
Date of issuance of certificate: q- L -ov, Date fee paid: 9-2-- 0?
Type of unit: Dwelling---v1 Other Check# Check date:
Notes: ?1-<O v, i�d (_aOIL k5rJ d-e_14Ox,743
Code Enforcement Inspector
CITY OF SALEM, MASSACHUSETTS
+ BOARD OF HEALTH
120 WASHINGTON STREET,4"FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR . tsco'rr@SA1,E1Nc COM.
JOANNE SCOTT,
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chanter 111; Code of Massachusetts Regulations 410.000 et. Seq.
State Sanitary Code Chapter II and Article XIII of the 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 authorized 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/out absence. I/we expressly authorized 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 lose or injury sustained of whatever nature and description occasioned by my/out absence
during said inspection.
Tenant/Lessee Owner/Lessor
Address Address
Address on unit to be inspected
Date