12 Hancock Street 2nd Floor Certificate of Fitness Application 2-15-2018 CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 W ASHINGTON STREET 4"`FLOOR PublicHedth
Prevent.Promote.Protect.
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL lramdin@salem.com
MAYOR L;1RRY R,�MDIN,RRT�S� IIS,CIIO,CP-I'S HIm;III 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 Z hF n N cn c-f� ST" SA`6M a�a -Loa CL� UNIT# "L
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNEWLESSER �� � C'o t' IN) MANAGER/AGENT
NO P.O. BOX
ADDRESS 12 ADDRESS
CITY, STATE,ZIP SA--c.E M MA O (qT O CITY, STATE,ZIP
RESIDENCE PHONE 9 `r BUSINESS PHONE(24HRS)
BUSINESS PHONE .!970<�- �97f3 "17 q q
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. i.1"`s '�2. t�1ti bQoQtn3 g6�rLv�.n 4 i�c iyrcAl 5. - czw).OD rem
6. A,ltl r-cb^^ 7.A8-'z °��O M 8. WbZz�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 one
Date on initial inspection: 5 r 1 Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# Check date: a 13
Notes:
Coe orc` ent Inspector
r
IIlr � s CITY OF SALEM, MA.SS.ACHUSETTS
BO.,�RD OF HE-ILTH
120 WASI-IINGTON STREET 4"'FLOOR PlibilGH� l
, Prevent.Promote.Protect.
TEL. (978) 741-1800 FAx (978) 745-0343
ItIMBI;RLEY DRISCOLL Iramdin@salem.com
salem.com
I✓�RR1':RAI�fI)1N,RS/RIB;I IS,CIlO,Cl'-1'S
MAYOR F II SAL;I'I I ACTL?,NT
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 i spectio
j' a-
Tenantnt e4 Owner/Lessor
'Z— K A N L o C.k S f S NZ-46 fn
Address Address
UNIT C;L- C>.`v'°
Address on unit to be inspected
Date
Updated 5/23/11