19 Hancock Street #3 Certificate of Fitness Application 5-1-2017 CITY OF SALEXI, MASSACHUSETI'S
Bo-xRD OF HEALTH
00 120 WASMNGTONKSTREET,4'Fu,)OR
TEL (978)741-1800
KBIBERLE-17 DRISCOLL FA_X,,9 8)
MAYOR
LARRY FUAIDIN,RS/RENS,CHO,CP-1t8
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE,CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FrfNESS FOR HUMAN HABITATION"
FEE:$50.00
PROPERTY LOCATED AT_Lq_j�4AC UNrf#
IS THIS UNIT MSIGNATM AS RIGHT LEFT FRONT OR SAC PLEASE CIRCLE ONE
0VVNERJLESSER MANAGER(AGENT
NO P.O.BOX
ADD ADDRESS
CITY,STATE,ZIP CITY,STATE,Z1P
-Ift
RESIDENCE PHONE Ik-
PHONE(24HRS),
BUSINESS PHONE Ll
1�f
TOTAL NUMBER OF ROOMS: L
ROOM USE: X&ckew-t,L�Lk 3. 5.
6. 7. S. 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 TwE OF P7;ON
f'7
APPLICANT'S SIGNATURE DATE -
%
hgW—mrs use only
Date on initial inspection: J f Date of reinspection:
Date of issuance of certificate.— Date fee paid. 5 IL/7 L
Type of unit: Dwe1ling_Other Check# "7 51 Check date:
. I r -
Notes:
/f,_JJ� Z=9
-7
Code Enfb\f"_n__*pector 1 53
t
C:I'IY OF SA -,FM MASSACHUSE`7S
BOARD OF HEALTI
120 WxS1-nNc;ToN S'rRE;f?'I',4`H FLOOR
TEL M8) 741-1800
K VIBERLEY DRISCOLL FAX(978)745-034.3
1Vit�YOR LR C�SALEb�COb4
LARRY RAMDIN,RS/RF-IIS,CIIO,CP-FS
MEAL TR AGEN'T
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts Regulations 410.000 et. Seq. ;
State Sanitary Code Chapter H and Article XIII of the City of Salem Ordinance, undersigned owner/lessor and
tenant/lessee of a unit of residential property,hereby authorize the Salem Board of Health or its authorized agents to
inspect the residence identified below in accordance with the aforementioned statutes,regulations and ordinances.
In the event it is necessary that said inspection be done in my/out absence. I/we expressly authorized the same and for
my/our successors and assigns hereby release and discharge the City of Salem, Salem Board of Health and its
authorized agents from any lose or injury sustained of whatever nature and description occasioned by my/out absence
during said inspection.
' t/Lessee Owner/Lessor
i f
Address Address
Address on unit to be inspected
Date
Updated 5/23111