8 Durkin Road Certificate of Fitness Application 10-16-2018 t
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MAYOR
Application for Certificate of Fitness
IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-705
"CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT,APARTMENT OR TENEMENT"
FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER II, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: S50.00
l'RC)P:F R IY I,OC:AT.IsD AT _ ti, , lez,�---------------- --------",-,------.-.----------,----.--.--.----.... 7' 1'� 1
is THIS UNIT DISIG A'11"D AS RIGHT L ET 'I�ONT OR BACK,._ PLEASE CIRCLE ONE
OWNER/LESSER , _�� MANAGE.Ri MiEN`1". ..._.._....
;� x �T131�ESS^..__. _..._. .. ._.__.ADDRESS µ. �.. .. � _ _... ._.. ..__._.___._.____._____.
CITY, STATE, GIP _ J, . _� �r,ITY, STATE,71.I'
RI.SIDENI CE PHONE—9
cl _ � I3USf ES P110NE(214FIR S)_
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:,.
WiItc4jLln PLAA
ROOM USE: 1. �.,_ 2 _. 3 _._ _ o_ _4 _ 5 O `l
Bedroom#ly ft2 Bedroom#2 ftz Bedroom#3 ft2 Bedroom#4 ft2
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK.OR MONEY ORDER TO THE,CITY OF SALEM
BOARD OF HEALTH THIS FEE I PAYAB E iE TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE /0_._._.... -:: _---____.. _.......
_ _
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Inspectors use only
Date on initial inspection:. _ _,_.._...._..._ Date of reins eetion:__.
Date of issuance of certificate; _ ..__. ___......... _ , _ Date fee paid:
Type of unit: Dwelling...._.......__......._.._Other Check# -— Check date:
Notes: