82 Derby Street Certificate of Fitness Application 8-20-2019 CITY OF SALEM, MASSACHUSETTS
A Bo RD of HEALTH
98 WASHINGTON STREET,3RD FLOOR PublicHealth
S A T L T ,MA
A 0 970 Prevent.Promote.Protect.
T
KIMBERLEY DRISCOLL EL. (978) 741-1800
MAYOR health@salem.com DAVID GREENBAUM
HEALTH AGENT
Application for Certificate of Fitness % <196-
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
PROPERTY LOCATED AT 2 D?P-5 UNIT# X
IF THIS UNIT IS DISIGNATED AS RIGHT,LhELQ!!!q OR BACK,PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES NO
OWNER/LESSOR 8�����( S-CP- �TI�I�G MANAGER/AGENT Ddggr LQegq`E - tr)
NO P.O.BOX
ADDRESS S3 41?'toe,t �new ADDRESS
CITY, STATE,ZIP B & r0ok Okq 2 i CITY, STATE,ZIP 'E�c QA Y Vim- Q1G2�
RESIDENCE PHONE CELL PHONE(24HRS) s- a 2f�5 IC7�O
EMAIL 6-ebRa. c7 CON\c . Oe-— Sc>b 1(-S 1 1 l j
TOTAL NUMBER OF ROOMS: 4 Rcc::rYIS ►-::S��t
ROOM USE: 1. 2. 3. 4. 5.
Bedroom#1 ft2 Bedroom#2 ft2 Bedroom#3 ft2 Bedroom#4 ft2
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYAB AT THE TIME OF INSPECTION
APPLICANT'S SIGNATU DATE r d
( Inspectors use only
Date on initial inspection: + a O'f Date of reinspection:
Date of issuance of certificate: Date fee paid: -O 11
Type of unit: Dwelling; Other Check# I f) Check date:-
Notes:
A .
Code Enforcement Inspect