GALLOWS HILL (003) CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
a 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
CERTIFICATE OF FITNESS
CERTIFICATE# 113-07
DATE ISSUED: 3/26/2007
Property Located at: 11 Gallows Hill UNIT#House
Owner/Agent: Jose Alvarado
Address: 29 Lakeview Avenue
City/Town: Danvers, MA Zip Code: 01923 24 Hour Phone: 978-777-3985
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
�/
Zane.--
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
/ CTTY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
• 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970 �� ,/ D
TEL. 978-741-1800
FAX 978-745-0343
JOANNE SCOTT, MPH, RS, CHO
Kimberley Driscoll HEALTH AGENT
Mayor
APPLICATION FOR CERTIFICATE OF FITNESS
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION". ''pp
PROPERTY LOCATED AT� —a W—s __ 61 UNIT #tj v�
IS THIS UNIT DESIGNATED
�AS"RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER(LESSER Ic��7��1 0 MANAGER/AGENT i
No P.O. Box _ No P.O. Box
ADDRESS(.t & U ;!qA tasY2 ADDRESS,
CITY �/\t1&'?, _ _CITY
RESIDENCE PHONE� _11Z'3ggSBUSINESS PHONE (24 HRS) j�qT—CHCS
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1vxicoz_ ± 2. IttAt% C63.Sa_1 4,Qe sa a
THERE IS A TWENTY-FIVE(S25.00) 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 SIGNATU
INS,PFCTORS USE ONLY
DATE OF INiTIAi INSPECTION _ —DATE OF REINSPECTION,
DATE OF ISSUANCE OF CERTI FICA TE 3=a t 'O_?._DATE FEE PAID ,_ 3
7
TYPE OF UNIT: DWELLINOTHER _. CHECK#!_ T CHECK DATE a
NOTES;-
CODE ENFORCEMENT INSPECTOR 9�2t3?9t