SUMMIT STREET4
l
u
SUMMIT STREET
a
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 5 S it Street
OWNER/AGENT: Minerva Young
ADDRESS: P.O. Box 3023
CERT-# 583-00
FEE $25.00
DATE: 09/07/2000
UNIT #: Rear
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 744-2120
NINE NORTH STREET
Tel: (978) 741-1800
Fax: (978) 740-9705
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
'-'JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT
CODE ENFORCEMENT INSPECTOR
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
APPLICATION FOR CERTIFICATE OF FITNESS
NINE NORTH STREET
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 (� ��(GG UNIT #
IS THIS UNIT DESIGNATED AS RIGHT LEFT FRONd BQ PLEASE CIRCLE ONE
No P.O.
ADDRE:
IANAGER/AGENT.
P.O. Box
CITYr�))JA/ +�-M CITY
RESIDENCE PHONEg797q�V.- /Ld BUSINESS PHONE (24 HRS.)
BUSINESS PHONER77, f�Z� a 7,0
• - • -•• --
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 SIGNATURI
DATE OF INITIAL INSPECTION q-? -U'9 nATF nF RFINRPFCTIr)N
T,
DATE OF ISSUANCE OF CERTIFICATE: -7 _C� DATE FEE PAID: 0-0
TYPE OF UNIT: DWELLINGYOTHER_ CHECK # a -_7Y CHECK DATEI-_7_0
CODE ENFORCEMENT INSPECTOR 9/28/98
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
gj 120 WASHINGTON STREET, 4TH FLOOR
a _ a SALEM, MA 01970
.pB4 TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE # 352-05
DATE ISSUED: 6/1/05
Property Located at: 5 Summit Street UNIT # 1 R
Owner/Agent: Morris Realty Trust
Address: 5 Summit Avenue
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 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//H[��EALTH
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
CODE ENFORCEMENT INSPECTOR
STANLEY USOVICZ, JR.
MAYOR
BOARD OF HEALTH
120 WASH I NGTON' STREET. 4TH FLOOR
SALEM, MA 01970
TEL. 978-74 1 -1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
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 yyJn'J At UNIT N /
IS THIS UNIT DESIGNATED A RIGH , LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER/°r�YrrS �Qa( (:
AGER/AGENT
_
No P.O. Box C No P.O. Box
ADDRESS
J �/L/{%J/j/ r� /`P ADDRESS
CITY_LJa— CITY
RESIDENCE PHONE 77e-- 7 Y6. % I/G
BUSINESS PHONE (24 HRS.)_
BUSINESS PHONF
TOTAL NUMBER OF BROOMS:
ROOM USE 1._�¢T,� 2r--_j'S�1__ 3 1� 4
S _ 6. (Q 7._ D —8.��
THERE IS A TWENTY-FIVE (525.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF S M HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE
TItJ1E OF INSPECTION.
APPLICANTS SIGNATU riyDAI ES U S�
INSPECTORS/USE ONLY
DATE OF INITIAL INSPECTION DATE OF REINSPFC110D
0A1 L OP
ISSUANCE 01= CERT1RCA1_E'5�-'D_r m 1-
DnTL
PGT. ('.UD
TYPE= OP
UN11- DWEI_LIN5/_ of R CHECK )'
,3 �'
i.I1(=�;y I)ATF
14')11
(,()I)1 I IJi ()I i(:1 MINI N';Pt CIoH
(1/7Y,!'J�f
KIWERLEY DRISCOLL
MAYOR
DAVID GRui NBAOM
ACTING Huitu.111 AGI N,r
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 461 FLOOR
TEL. (978) 741-1800
FAx (978) 745-0343
DGIZI?FNIIAUM@SAl PM COM
CERTIFICATE OF FITNESS
CERTIFICATE # 244-10
DATE ISSUED: 5/24/2010
Property Located at: 12 Summit Street UNIT # 1
Owner/Agent: Eugene Polnicki
Address: 23 Haskell Street
City/Town: Beverly, MA Zip Code: 01915 24 Hour Phone: 508-527-3502
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 OF HEALTH
DA 4�//�EEN,
DGRBAUM
ACTING HEALTH AGENT CO E EI FORCEMENT INSPECTOR
ICIMBERLEY DRISCOLL
MAYOR
DAVID GREENBAUM,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4` FLOOR r , / O
TEL. (978) 741-1800 "�
FAX (978) 745-0343
DGREENBAUM&ALLM. COM
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION."
fc� ..JVMMI4 FEE: $50.00
PROPERTY LOCATED AT < i _ i ? '34. UNIT#_
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK, PLEASE CIRCLE ONE
OWNER/LESSER!�P_ i—�L., rO L�W l t.K 1 MANAGER/ AGENT
NO P.O. BOX
ADDRESS 2 3 i t A s F L1 S i ADDRESS
CITY, STATE, ZIP I,� �_7 SIE lzb-4 MA M I T CITY, STATE, ZIP
RESIDENCE PHONE 5-08- BUSINESS PHONE (24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: 4
ROOM USE: 1.K4 HP -t,/ 2. 11Y� 3. DEN 4. r3X5'0AtyL)0C -''1
6. 7. 8. 9. 10.
THERE IS A FIFTY ($50) DOLLAR FEE, PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
RD
BOAOF HE - — -
APPLICANT'S
Inspectors use onl
� l
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: Date fee paid: S d �/y
Type of unit: Dwelling Other Check #Check date: S I A 0% l / 0
:V,dThTWAM
Co �cement Inspector
KIMBERLEY DRISCOLL
MAYOR
DAVID GREENBAum,
ACTING HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, *'FLOOR
TEL. (978) 741-1800
FAX (978) 745-0343
DGREENI3AVM@SA1XM. COM
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 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
� Date
Owner/Lessor
Address
Address on unit to be inspected
2/8/06
Manuel A Silva
105 Goodale Street
Peabody, MA 01960
PROPERTY LOCATED AT 16 Summit 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.
or the Board of Health
h
//Joanne Scott MPH, RS, CHO
Health Agent
Reply to
Pablo Valdez
Code Enforcement Inspector
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
Kimberley Driscoll
WWW.SALEM.COM
Mayor
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
2/8/06
Manuel A Silva
105 Goodale Street
Peabody, MA 01960
PROPERTY LOCATED AT 16 Summit 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.
or the Board of Health
h
//Joanne Scott MPH, RS, CHO
Health Agent
Reply to
Pablo Valdez
Code Enforcement Inspector
CITY OF SALEM, MASSACHUSETTS
�+ BOARD OF HEALTH
$t 120 WASHINGTON STREET, 4TH FLOOR
a SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE # 123-05
DATE ISSUED: 2/24/05
Property Located at: 20 Summit Street UNIT # 2
Owner/Agent: Cecelia Wu
Address: 5 Daniels Street
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 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
J, --
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
CODE ENFORCEMENT INSPECT
STANLEY USOVICZ, JR.
MAYOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
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 -20 &,MM I7 UNIT #�
IS THIS UNIT DESIGNATED AS RIGHT LEF I FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER,� j; a MANAGER/AGENT
No P.O. Box No P.O. Box
ADDRESS S TtitYljpa < ADDRESS
RESIDENCE PHONE t?t BUSINESS PHONE (24 HRS.)_
BUSINESS PHONE (oll 9!�
TOTAL NUMBER OF ROOMS:____
ROOM USE: 1.. fVIK
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. f
APPLICANTS SIGNATURE ATE �• - ��J
INSPECTORS USE ONLY
DATE OF INITIAL INSPECTION .�-z. o �DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE2 DATE FEE PAID. 2 �o 5-
TYPE OF UNIL DWELLIN OTHER__ CHECK #_1 _/_ q_ZCHECK DATE _z__ -y y
NOTES
CODE ENFORCEMENT INSPECTOR
r
CITY OF SALEM, MASSACHUSETTS
BOARD HEALTH
R
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
WW W.SALEM.COM
Kimberley Driscoll
JOANNE SCOTT, MPH, RS, CHO
Mayor
HEALTH AGENT
COMMONWEATLH OF MASSACHUSETTS
CITY OF SALEM
EXTERIOR PAINT REMOVAL PERMIT
Property located at: 29 Summit Street
Owners name: Tim Hamm
Address of owner: 29 Summit Street
Contractor's name: George Tanch
Business name:
Address of contractor: 67 Blueberry Lane
Date paint removal will occur: 8/29/07 - 9/14/07
Hours paint removal will occur: 8am - 5pm
This license is granted in conformity with the statutes and ordinances relating to exterior
paint removal.
Permit #: 40-07
Application date: 8/29/2007
Permit Expires: 9/14/2007 unless suspended or revoked
NO ELECTRIC SANDING
HEALTH AGENT
Kimberley Driscoll
Mayor
CITY of SALEM, MASSACHUSETTS
BOARD OF HEALTH - -
.120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
W W W.SALEM.COM
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
APPLICATION FOR PERMIT TO ENGAGE IN EXTERIOR PAINT REMOVAL
Date: '�K 1 -2q l o-7 Property Located at:a_ 9
Owners Name' M HAW
Address of Owner (if different from above)
Telephone Number q-)% %?q q 3441
Contractor/Name of person/agency that will perform paint removal:
no
Address of Cont
Date an � hours
RV2 9 lo -a
Type of Exterior
Telephone Number 1)9 Get(. I/1&'5—
faint removal will occur:
(2 oda Cl -
I to be Performed -Please Describe:
Clean -Up PMocedures- Please Describe: .sw,o VA��,, �� ell Innes 6
I have read the Board of Health " Regulation 23 Rules and Regulations". I have had the
opportunity to ask questions regarding those Rules and Regulations. I understand them,
agree to abide by them and understand that failure to do so may result in fines and/or in
revocation of my Exterior Paint Removal Permit.
Persuant to MGL,C62c,S49A, I certify under the penalties of perjury that I, to my best
knowledge and belief, have filgd all State tax returns and paid all State taxes required under
law.
Signature
Social Secruity or F
I D#
For Board of Health Use Only
Approved by:
Date Permit l5sued
Permit # -d
KIMBERLEY DRISCOLL
MAYOR
DAVIU GRC?GN13AUM
Ac'i ANG HriAl;ri-I AGr.?NI'
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4°f FLOOR
TEL. (978) 741-1800
FAx (978) 745-0343
DGRF, F.N BAUM@SAIA3.M.CQM
CERTIFICATE OF FITNESS
CERTIFICATE # 26-10
DATE ISSUED: 1/22/2010
Property Located at: 30 Summit Avenue UNIT # 2
Owner/Agent: Marie Gagnon
Address: 8 Cleary Lane
City/Town: Topsfield, MA Zip Code: 01983 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 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
�.. C
DAID GREENBAUM
ACTING HEALTH AGENT CODft1FJFORCEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS 1
• BOARD OF HEALTH
120 WASHINGTON STREET, 4"' FLOOR _
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx (978) 745-0343
MAYOR 1SCar1'e SA1 rM COnI---
- -
JOANNESCOTT,
HEALTHAGENT JAN 2 8 2010
C1.. A
BOARD OF HEALTH
Application for Certificate of Fitness
-INACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION."
FEE: $50.00
PROPERTY LOCATED AT "�, C) S ys + I -J Vt— UNIT# ?-
IS THIS UNIT DI$IGNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSER CS`*r(z�vJ MANAGER/AGENT
NO P.O. Box
ADDRESS ADDRESS
CITY, STATE, ZIP bQS _. N—ND 1"18 Z CITY, STATE, ZIP
RESIDENCE PHONE �"t R — B8 1-8$S BUSINESS PHONE (24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: h
ROOMUSE: 1. 2. S£D 3. ?Vop 4.%--%-/ 5. c>mr�Tz—
6. hs 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 SIGNATUREDATE '2S 'ICS
Inspectors use only
Date on initial inspection: o � U Date of reinspection:
Date of issuance of certificate: I IdQ / U qq Date fee paid:
Type of.unit: Dwelling ✓Other- - - Check #-7 I 1 Check date: 70
KIMBtkLEY DRbSCOLL
MAYOR
JOANNE SCOTT,
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
WARD OF HEALTH
ljo WASHINGTON STREET, 4"' FLOOR
TFL. (978) 741-1800
FAX (918) 745-043
TSCOTI&ALEW COM:
Release
4
In accordance with Massachusetts General UfWs Chapter I I I, Code of Massachusetts R691-ildtion"s 416.000 et. Seq,
State SahitRy Code Chapter 11 and Article XIII of the City of Salem Oidmian6e, undersigned owner/lessor and
tenant/ldske of a unit of residential pr6pertyehdfdby, dfifhofizathd Sdl.bffi Board of Health or its duffi6fized agents to
inspect the fid§idehre identified below in a4cdbbd-6A-c6 With the aforementioned statutes, regulations and ordinances.
x
In the event it is necessary that said inspection be done ffiiny/out absence. I/We- expressly auth6rized the sane and f6r
nly/0 U -r- successors and assigns hereby . release.afid dis.chdige the City of Saleffi, 8alem)3oa'rd ofh6afth and its
authorized agents from any lose of injury sustained of whatever` nature and description occasioned by rft ut absence
ever ure my/out
during said inspection.
Tenant/Lessee Ownei /Lessor
Address Address
on unit to be inip66ted
Date