1000 Loring Ave #C-086 Certificate of Fitness Application 5-1-2017 CITY OF SALEM, MASSACHUSETTS
. • BOARD OF HEALTH
120 WASHINGION STREET,4'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOIJ- F-X(978) 745-0343
MAYOR LRAMDIN SALEM.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 AT 1000 LORING AVENUE _UNIT#_ C-086
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR EACIC,PLEASE CIRCLE ONE
OWNEWLESSER LORING TOWERS MANAGER/AGENT YVETTE VALERIO
NO P.O.BOX
ADDRESS 1000 LORING AVENUE ADDRESS
CITY, STATE,Z,IP_— SAL'GM MA 01970 TCITY, STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS)
BUSINESS PHONE 978-745-2055
TOTAL NUMBER OF ROOMS: 40
ROOM USE: 1.Livin •oom 2.Kitclieii 3.Batliroom 4.Bedroom S.Bedroom
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
T�I1ME OF INSPECTION
APPLICANT'S SIGNATURE U C LLU,� DATE-6
Ins ectors use only
Date on initial inspection:��`f Date of reinspection:
Date of issuance of certificate:----- Date fee paid:__ — _,__
Type of unit: Dwelling Other Check# Check date:
Notes:
Cone E. rcemm�nt Inspector
CITY OF SALEM, MASSACHUSETTS
�� tf
BOARD of HEALTH
120 WASHINGTON STREET,4"'FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR LRANIDIN(NSMYUCOM
LARRY RANIDIN,RS/REHS,CHO,CP-FS
HEALTH AGENT
Release
In accordance with Massachusetts General Laws Chapter 111; Code of Massachusetts Regulations 410,000 et. Seq. ;
State Sanitary Code Chapter 11 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 ir.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.
Tenant/Lessee O r/Lessor
1000 LOR NG AVENUE, SALEM MA 01970 1000 LORING AVENUE, SALEM MA 01970
Address Address
C-086
Address on unit to be inspected
Date
Updated 5/23/11