21 HAZEL STREET 0`°N ,. City of Salem, Massachusetts
f � ►
Board of Health
" 120 Washington Street, 4th Floor, Salem, Puh1�CHealith
MA 01970 rrclent.Promote.a rota.
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin,MPH,REHS,CHO
Mayor health@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE#: GHL-17-384
DATE ISSUED: 11/9/2017
Property Located at: 21 HAZEL STREET UNIT#3
Owner/Agent: Marshall Strauss
Address: 10 Chestnut Street
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone:
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division 3, Section 705: Certificate of fitness of
rented dwelling unit, apartment or tenement. 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 Fitnessis valid only if there is a valid Certificate of Occupancy.
Note: This approval does not certify compliance with the state lead law for occupants under 6 years of age.
HEALTH AGENT SANITARIAN
Larry Ramdin, MPH, REHS, CHO
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON SMWh-T,4?"11-0011
TEL(978)741-1800
IGMBERLF,Y DRISCOLL FAX(978)745-0343
MAYOR IBAMDRQ0sA1EM.Q)M
LARRY RAMDIN,RS/RFJIS,CHO,CP-PS
HEnLTHAcraIT
_ R rSh c u\- '�-*r ac u S7
Application for Certificate of FlI ness
IN ACCORDANCE W rTH STATE SANITARY CODE,CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
f FEE- $�5r0.00
PROPERTY LOCATED AT C�
IS TRIS MY DISIGNATED AS RIGAr LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNMWXSSER Q Pf AU I I -Ct-60 v f MANAGER/
AGEN
T
ScPsDRE / �r ADDRESS
CITY,STATE,ZIPLRP/ 4f4 Olq'2U CITY,STATE,ZIP
RESIDENCEPHONE � 7s'— SV - �0u7BUSNESS PHONE(24HR )
BUSn46SSPHONE2E/ — -- q
P— (�? !f)
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 2 2. PR 3. ' \ 4. ?IQ 5.
6 �7.0 c 8. 9. 10.
THERE IS A F1I;TY($50)DOLLAR FEE,PAYAB1,P BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYATI THE TRIM OF INSPECTION
APPLICANT'S SIGNATURE DATE 40
//-J -1 -2
Inspectors use only
Date on initial inspection: Date of reinspection
Date of issuance of certificate: Date fee paid .
Type of unit: Dwelling_Other Check#— Check date:
Notes: ^�� fj aU g24
,
Code Enforcement Inspector