21 BECKET STREET 11-14-2019 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHIN�GTT�ON STREET,3RD FLOOR P1 CHean
SALEM,MA 01970 Prevent.Promote:Protect.
TEL. �97s) 741-lsoa
KBvIBERLEY DRISCOLL health salem.com DAvID GREENBAum
MAY0* e HEALTH AGENT
Application for Certificate of Fitness
IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-705
"CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT,APARTMENT OR TENEMENT"
FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000 �
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00 � C/I
PROPERTY LOCATED AT �' c'-� 1JN1T#
IF THIS UNIT IS DISIGNATED AS RIGHT,LEFT,FRONT OR BACK,PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES N0>5�
OWNER/LESSOR �! T'� �l MANAGER/AGENT
NO P.O.BOX
ADDRESS l ' ADDRESS
CITY, STATE,ZIP LC'I LI VMvk 0 I `1Z CITY, STATE,ZIP _
RESIDENCE PHONE 0; j Zf'Z �i S CELL PHONE(24HRS)
EMAIL
TOTAL NUMBER OF ROOMS:
ROOM USE: 1.—;C 1t&— , 2._L I s 3. 1-zA f6nV0 4. --- 55.
Bedroom#1 ftz Bedroom#2_ _ftz Bedroom#3 ft Bedroom#4 ft2
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF 9 kLEM
BOARD OF HEALTH THIS FEE IS AYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE ADATE I
Inspectors use only
1 �
Date on initial inspection: 11" Date of reinspecti n:
Date of issuance of certificate:— Date fee paid: i
Type of unit: Dwelling_ Other Check# 0:1 Check date: I a
Notes:
Code Enforcement Inspector r , ,- -
i
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR PubUcHean
Pr`"°a`:prom Protect.MA 01970
TEL.. (978) 741-1800
KIMBERLEY DRISCOLL health&salem.com DAviD GREENBAUM
MAYnk' T HEALTH AGENT
Application for Certificate of Fitness f
IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-705 .�
"CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT,APARTMENT OR TENEMENT"
FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE• $50.00 �
KZ
PROPERTY LOCATED AT 2 \ 1
eye trNIT# 2
IF THIS UNIT IS DISIGNATED AS RIGHT,LEFT,FRONT OR]BACK,PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES NO'�tZ
OWNER/LESSOR '.1 8 i�" b I CJ\ MANAGER/AGENT
NO P.O.BOX .
ADDRESS -ADDRESS
CITY, STATE,ZIP `��Wt� � _CITY, STATE,ZIP
RESIDENCE PHONE SO S -1 CELL PHONE(24HRS)
�� 1Y1 lS4� m CLS4'✓1
EMAIL _ m Vl�ld,
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. V_ 2. L e `/16VA A 4. rc�i c�v��c 5.
Bedroom#1 Y _ft2 Bedroom#2 %--/ W Bedroom#3 ✓ ftZ Bedroom#4 ftz
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF S!NLEM
BOARD OF HEALTH THIS FEE ' PAYABLE AT THE TIME OF INSPECTION
J4/APPLICANT'S SIGNATURE _ DATE
InsRectors use only
Date on initial inspection: ( Date of reinspects n:
Date of issuance of certificate:. Date fee paid: l' (f I C
Type of unit: Dwelling:.. Other Check# 69 C1 Check date: h 1 I- f C
Notes:
Code Enforcement Inspector 4,