1000 Loring Ave #B-072 Certificate of Fitness Application 5-1-2017 I CITY OF SALEM, MASSACHUSETTS
., e BOARD OF HEALTH
120 WASHINGTON STREET,4"-FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR LRAMDIN f@S,'J.F.M.COM
LARRY RAMDIN,RS/REHS,CHO,CP-FS
HEALTH AGENT
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00
PROPERTY LOCATED AT1000 LORING AVENUE __, UNIT# B-072
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
ONVNER/LESSER LORING TOWERS MANAGER/AGENT YVETTE VALERIO
NO P.O.BOX
ADDRESS 1000 LORING AVENUE ADDRESS
CITY, STATE,ZIP SALEM, MA 01970 _CITY, STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS).
BUSINESS PHONE 978-745-2055
TOTAL NUMBER OF ROOMS: l
ROOM USE: I.Livingroom 2.Kitchen 3.Bathroom 4.Bedroom 5.
6. 7. 8. 9 10.
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE
Inspectors use only
Date on initial inspection: S Ity Date of reinspection:
Date of issuance of certificate:___ Date fee paid:_ _ _
Type of unit: Dwelling Other Check# Check date:
Notes:
a17
Code E rci4j; t Inspectcr "�