BELLEVIEW AVENUE CITY OF SALEM, MASSACHUSETTS
m31. BOARD OF HEALTH
ro
120 WASHINGTON STREET, 4TH FLOOR
�Pa SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343
KIMBERLEY DRISCOLL JSCOTT@SALEM.COM
MAYOR
JOANNE SCOTT
HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#96-08
DATE ISSUED: 2/26/2008
Property Located at: 25 Belleview Avenue UNIT# 1
Owner/Agent: Pamela Colburne
Address: 11724 Lariat Lane
City/Town: Oakton, VA Zip Code: 22124 24 Hour Phone: 617-314-9007
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 ll"
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, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever
is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
FOR THE BOARD OF HEALTH
JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
• 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800 D
FAX 978-745-0343 -
JOANNE SCOTT, MPH, RS, CHO
Kimberley Driscoll HEALTH AGENT
Mayor
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 � /
J 1'1 V'-& UNIT#/
IS THIS UNIT DESIGNATED AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER Pu„ G01bwou- MANAGER/AGENT
No P.O. Box I � � �t166 No P.O. Box
ADDRESS III1y �Kiai' I� ADDRESS
CITY__ U(LLIv-\ Vk CITY
RESIDENCE PHONEIV31+1+ 007 BUSINESS PHONE (24 HRS.)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1.--
5--6.—T-8.
_5.__6. 7. 8.
THERE IS'A TWENTY-FIVE($ ) DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF S EM EALTH D ARTMENT THIS FEE IS PAYABLE AT THE
TIME OF INSPECTION. ,/ n �j
APPLICANTS SIGNATURE / DATE 2.�o CJO
INSP RS-USE ONLY
DATE OF INITIAL INSPECTION 6—DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE`2 L o3 DATE
�FEE PAID: '2- � 6_�J S
TYPE OF UNIT: DWELLING _OTH� CHECK #1dSCJ__CHECK DATE :- l 9
NOTES:
CODE ENFORCEMENT INSPECTOR 9/28/98