12 Hancock Street Right Certificate of Fitness Application 2-15-2018 CITY OF SALEM, MASSACHUSETTS 10
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BOARD OF HEALTH
120 W ASHINGTON STREET 4"FLOOR 1�llbhCHP��1
� Prevent.Promote.Protect.
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin Isalem.com
MAYOR L:\RRY 12,11vIDIN,RS/REI3S,CI-IO,CP-IDS
HF,:1L1'1I 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 12, N A N v C,� S t �-t M UNIT# S e—
IS THIS UNIT DISIGNATED A5 RI 'LEFF FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER `1�� � C.t� ( MANAGER/AGENT
NO P.O.BOX
ADDRESS 1ofV C a c_y S f ADDRESS -
CITY, STATE,ZIP ��-� M w O V11 0 CITY, STATE,ZIP
RESIDENCE PHONE qz x Sn el `l BUSINESS PHONE(24HRS) T��
BUSINESS PHONE S'o€s .k7 2 1 7 R
TOTAL NUMBER OF ROOMS: \
ROOM USE: 1. LcP ti g 2. P��^� 3. �hn►�1RreM 4. k-�ta�J�J _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: a Date of reinspection:
Date of issuance of certificate: Date fee paid: a 5
Type of unit: Dwelling Other Check# Check date: T�1 S �I
Notes:
Coe orc ent Inspector
CITY OF SALEM, MASSACHUSETTS
Bo, RD OF H E_1LTH Public Health
120 WASH ING`I'ON STREET,4nt hLOOR Prevent.Promote.Protect.
TF,L. (978) 741-1800 FAx (978) 745-0343
KIMBERLI?Y DRISCOLL ]ramdin salem.com
L;1I2R1:'.K;1A:fDIN,RS/ltl�,l-.IS,CIIO,CP-F5
MAYOR III f AmI NT
Release
In accordance with Massachusetts General Laws Chapter 11 l; Code of Massachusetts Regulations 410.000 et. Seq. ;
State Sanitary Code Chapter II 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/our 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 loss or injury sustained of whatever nature and description occasioned by my/our absence
during said inspection.
L;en t/Lessee Owner/Lessor
� c . rr Q I � Sa w�/ 1
�� N G0 GAG S1 <W , �/
Address Address
12
Address on unit to be inspected
Date
Updated 5/23/11