12 Hancock Street Left Certificate of Fitness Application 2-15-2018 CITY OF SALEM, IVIASSACHUSETTS lu
BOARD OF HEALTH PublicHedth
120 W ASHINGTON STREET,4 "FLOOR Prevent,Promote.Protect.
TEL. (978) 741-1800 FAX(978) 745-0343
KIMBERLEY DRISCOLL Iramdin@salem.com salem.com
L:1RRY R;IMDIN,RS/ItET3S,CI-IO,(:P-FS
MAYOR HEAL: 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 1 Z VY C� S S A-t,G-/VN UNIT#
IS THIS UNIT DISIGNATED AS RIGI 'I'LE FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER H1�2 MANAGER/AGENT
NO P.O. BOX
ADDRESS 9A 1 rot,' _ADDRESS
CITY, STATE,ZII'_ S�-t-� �^ CITY, STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS) _
BUSINESS PHONE S 27 d—.Cy�7
TOTAL NUMBER OF ROOMS: 5
ROOM USE: 1.0 V ► 5 2. rA-v- i L 3. :6(Lmm 4. 2 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: Date of reinspection: '
Date of issuance of certificate: Date fee paid: f 5�1
Type of unit: Dwelling Other Check# 3Ljtj Check date: a S n
Notes:
Code nfo t Inspector
• Q�
CITE OF SAr EM, MASSACHUSETTS
BOARD OF HEALTH
120 WASI-TI.NGTON S'I"REFT,4"1 FLoOR PllblicHealth
Prevent.Promote.Protect.
'Io- (978) 741-1800 FAx(978) 745-0343
KTMBJ::,'RJJ7,Y DRISCOLL lramdin@,salem.com
I.,A.ItItY R;1T\ID1N,RS/KI?l[S,C:1-IO,CP-FS
MAYOR III?:11;I'I1 t�Cil?N"7"
Release
In accordance with Massachusetts General Laws Chapter 111; 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.
11Z4
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Tenant/Le ee Owner/Lessor
Address Address
Address on unit to be inspected
Date
Updated 5/23/11