6 ATLANTIC STREET ���orioir
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CERT.# 55-02
FEE $25.00
�oDATE: 02/04/2002
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CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970
JOANNE SCOTT, MPH, RS,CHO 120 Washington Street — 4" Floor
HEALTH AGENT Tel # (978)-741-1800
Fax # (978)-745-0343
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 6 Atlantic Street UNIT #: #2 2nd floor
OWNER/AGENT: Roy Lapham -
ADDRESS: 4 Atlantic Street
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 744-7295
AN INSPECTION OF YOUR VACANT DWELLING/ROOMING UNIT AT THE ABOVE ADDRESS HAS
BEEN APPROVED AND IS IN COMPLIANCE WITH 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
THEREFORE, THIS CERTIFICATE IS ISSUED BY THE CODE ENFORCEMENT DIVISION OF THE
SALEM BOARD OF HEALTH AND THE UNIT MAY NOW BE RENTED AND/OR OCCUPIED.
MAXIMUM NUMBER OF OCCUPANTS, BASED ON 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
SECTION 410 .400 (B) : DWELLING UNIT (X) AND 410.400 (C) : ROOMING UNIT
MINIMUM SQUARE FOOTAGE FOR SLEEPING PURPOSES: .
NOTE: THIS APPROVAL DOES NOT CERTIFY COMPLIANCE WITH THE STATE LEAD LAW FOR
OCCUPANTS UNDER 6 YEARS OF AGE. FOR MORE INFORMATION CALL 978-741-1800 .
OR THE BOARD H
JOANNE SCOTT, MPH,RS,CHO
I
i
CITY OF SALEM, MASSACHUSETTS O 9
'� BOARD OF HEALTH
• 120 WASHINGTON STREET, 4TH FLOOR
3
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
STANLEY USOVICZ, JR. ,JOANNE SCOTT, MPH, RS, CHO -
MAYOR HEALTH AGENT
APPLICATION FOR CERTIFICATE OF FITNESS
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION".
PROPERTY LOCATED AT •6 A TLA N Tt G -57-, SA i_Ern UNIT# Z = 2 Np �L •
IS THIS UNIT DESIGNATED AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSEW� L.blONA-✓Y� MANAGER/AGENT
No P.O. Box ' No P.O. Box
ADDRESS 4-ATL-ANTIC ST• ADDRESS
CITY 5:A J,6-r-0 rZW CITY
RESIDENCE PHONE 978-7YY-72KBUSINESS PHONE (24 HRS.)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1._A`j7 2.&uW_�_3. E 2. 4.aep 3
5. D e* . VC/ 7. 8.
THERE IS A TWENTY-FIVE($25.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE
TIME OF INSPECTION.
APPLICANTS SIGNATURE DATE 2-/- O Z
PECTO S USE ONLY
DATE OF INITIAL INSPECTION 2 ' '' L DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE: _ Lf —DATE FEE PAID: -2-
TYPE
TYPE OF UNIT: DWELLING OTHER_ CHECK# a a CHECK DATE
NOTES:
CODE ENFORCEMENT INSPECTOR 9/28/98
,Ncoxwt CITY OF SALEM, MASSACHUSETTS
���' � BOARD OF HEALTH
'� 120 WASHINGTON STREET, 4TH FLOOR
3
SALEM, MA 01970
'DBp� TEL. 978-741-1800 ..
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
RELEASE
In accordance with Massachusetts General Laws Chapter III ; 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 Hoard of Health or its author—
ized 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, 1/we
expressly authorize the same and for my/our successors and assigns hereby release
i and discharge the City of Salem, Salem Board of Health and its authorized agents
L .,, -�F.o-�t any loss or injury sustained of whatever nature and description occasioned
by my/our- absence during said inspection.
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ADDRESS ADDRESS
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ADDRESS OF UNIT TO BE INSPECTED
2-01. -oZ
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