Highland Condo Pool Permit Application 5-18-2021 RE CEIVED
s MAY 2 4 2021
CITY OF SALEM, NIASSACHUSEZT of sa�Enn
BOARD OF HEALTH BOARD OF HEALT�i .licHealtli
120 WASIu3GTON STREET,4T"FLOOR PPrreeennt.Promote.Protect.
TEL(978)741-1800 FAX(978)745-0343
KIMBERLEY DRISCOLL health@salem.com
LARRX RAMDIN,RS/REHS,CHO,CP-FS
MAYOR HEALTH AGENT
APPLICATION FOR PERMIT TO OPERATE A SWIMMING POOL
LOCATION OF POOL 0� U % ��
NAME OF APPLICANT I ��'TEL# ���'�11'1t?C U0 '
MAILING ADDRESS U� 0
EMAIL ADDRESS ��`� ;' �L1�'`Itle 7-
CERTIFIED POOL OPERATOR
Name- �� /U�S Cert#: k3eV I dV TEL# �' ��' /0
r
DATES OF OPERATION(if not annual);_
DAYS &HOURS OF OPERATION: II 1 Ij '4
TYPE OF POOL
Public
Semi-Public �.
Special Purpose _
Square Footage POD sf Volume b all J gallons Bather Load
FEE: $210.00 for year-round pools $140.00 for seasonal $40.00 Non-Profit
(Please pay total with one check payable to the City of Salem)
This permit is not transferable and must be reissued upon change of ownership.
In accordance with the State Sanitary Code,before any renovations,improvements,or Equipment changes are made,all plans
for such must be submitted to and approved by the Salem Board of Health.
Pursuant to MGL Chapter 6 3C,Section 49a,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,
led all state—tax rer,:r s and naid all state taxes required under the law.
Signa Date SS-9 or Federal Identification Number
Check# T— Date -� Amount M o�
Revised 512Y2017 poolappl Ldoc