SPRUANCE WAYhik
tf r Moo
KIMBERL,EY DRISCOLL
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4" FLOOR
TEL. (978) 741-1800 FAx (978) 745-0343
h-amdin@salem.com
CERTIFICATE OF FITNESS
CERTIFICATE # 409-12
DATE ISSUED: 10/16/2012
Property Located at: 2A Spruance Way UNIT #
Owner/Agent: Pamela C. Reynolds
Address: 4 Sunridge Road
City/Town: Windham, NH Zip Code: 03087 24 Hour Phone:
IJ
PublicHeaIth
P -1m 1. I'mmotc. Prola,.
L,AIM RrA MDIN, ItS/RF1 IS, 010, ORFS
HI__?r\I;I'1-1 ADEN'1'
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 THE BOARD OF HEALTH
LARM6 RAMDIN
HEALTH AGENT
6
w, 1
SANITARIAN
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HFI,LTH
120 WASHINGTON STREET, 41H FLOOR
TET.. (978) 741-1800 FAY (978) 745-0343
lramdin@salem.com
PublicHealth
1'rcvenl. l4omnle Frotco.
LARRY R,AM1>IN, RS/REI IS, CHO, Ch -FS
HFAL; l'l l AC;13N'I'
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
AL
PROPERTY LOCATED AT ATX
IS THIS UNIT
NO P.O. BOX
r U.an cz L,,�
UNIT#
TED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
CITY, STATE, TE, ZIP W i ad t ctr N`L_ t 0, 20- $7 CITY, STATE, ZIP_
�e-E PHONER:?i�' TD7 � �I Q �BUSINESS PHONE (24HRS
BUSINESS PHONE
TOTAL NUMBER OpF�"ROOMS: / d-,4 in
ROOM USE: 1.1 4 000 2. kJ(_004) 3. Ki I vtell4. 1 IV IA
THERE IS A FIFTY ($50) DOLLAR FEE, PAYABLE BY CHECK OR MONEY ORDER TO THE CIT OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S
Inspectors use only
Date on initial inspection: (0 Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check #._ :Check date:
Code
E
KIMBERLEY DRISCOLL
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WAST-IINGTON STREET, 4... FLOOR
TEL. (978) 741-1800 FAti (978) 745-0343
Iramdinna,salem.com
Release
LARRY RAMDIN, RS/RHI IS, (A 10, CP -FS
I IIIA I; I'I-I A(:, ISN P
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 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
Address
lobi /,Z -
Date
Updated 523/11
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Owner/Lessor
q�n��� �� e � Nib o�GFy
Address
Address l -
on unit to be inspected
0
KIMI3OU,EY DRISCOLL
MAYOR
LARRY RAN1DIN, RS/RHI IS, CI O, C11-18
IIr•.,u:rn Acr,N r
To:
Fax
RE:
Date
CITY OF SALEM, MASSACHUSETTS
BOARD of: Hi,u::rrt
120 WASI [INGTON STRGFr, 4"' Fi.()>R
'lTrr.. (978) 741-1800
F.\X (978) 745-0343
lramdinQsalun.com
Facsimile
Transmittal
Page(s): including this cover # —&
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