4 Hodges Court Certificate of Fitness Application 4-12-2018 ` CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4rH FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978) 745-0343
MAYOR LRAMDIN@SALEM.COM
LARRY RAMDIN,RS/REHS,CHO,CP-FS
HEALTH 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 Y Hod9eo GT UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CHICLE ONE
OWNE ESSER uua R-o bleS _MANAGER/AGENT
NO P.O.BOX (� B S' Cr
ADDRESS b
. j ADDRESS
CITY, STATE,ZIP s em CITY, STATE,ZIP M?'S., 01 q-7 0
RESIDENCE PHONE 5�� a'?°� O21�BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: {" QL+
ROOM USE: U.. 1 2. 3. V:)P—d, 4. 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
,,QQAT'�THE TIME OF INSPECTION
APPLICANT'S SIGNATURE ' (V, DATE
Inspectors use only
Date on initial inspection: Date of reinspects n:
Date of issuance of certificate: Date fee paid. ; 1
Type of unit: Dwelling Other Check# Check date: q a
Notes:
Co&-0fbr&ment Inspector
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