3 Ropes Street #1R Certificate of Fitness Application 4-11-2018 4N W&--"�
CITY OF SALEM, MASSACHt1SETTS
B O,�.RD OF LI E:�LTH
120 WASHINGTON STREET,4'F"FLOOR Pt
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TEL. (978) 741-1800 R.� (978) 745-0343
KIMBERLEY DRISCOLL lramdin sale .com
MAYOR L�jziw 1t,-\,mDIN,RS/REI-IS,C1iO,CY-tS
HEALTH AGENT
AGENT
kppi7cation for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 4M000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00
PROPERTY LOCATED AT `3 h cW>
Is THIS UNrr DISIGNATED AS GII f LEFT FRONT OR BACK.PLEASE CIRCLE ONE
OWNER/LESSER a
NO P.O.BOX M 1NACiL R°AGENT
"DRESSY
CITY, STATE,ZIP ��r�x�L ,`i. r"t`c') crry, STATE,21P
RESIDENCE PHONE
---)BUSINESS PHONE(24PIRS)_..Cam(
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: . f ,.<< 2.
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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 _ nT3ATE-3' (!L,c�
//rr Inspectors use only
Date on initial inspection; "tL Date of reinspec 'on:
Date of issuance of certificate: Date fee paid: a �J - _.
Type of unit: Dwelliu -Other Check it 117-0-5—_Check date: I _
Notes:
o��ent Inspector 10