22 Hardy Street Certificate of Fitness Application 5-23-2018 s
CITY OF SALE1VI, MASS.ACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET,4"FLOOR ftom,eft
TEL. (978) 741-1800 FAX(978) 745-0343
K MBERLEY DRISCOLL Iramdin(Rssalem_com LIRRY ltAMPIN,RS/REFIS,CHO,CP-i-
MAYOR
HE.II.TF I AGENT
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
'MMMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00
PROPERTY LOCATED AT _/1,1712-1� 9 , ���2�- _. UNIT#
Is THIS UNTT DISIGNATED AS RIGHT LEFT FRONT OR BACK.PLEASE CIRCLE ONE
OVVNERJLESSER A^A MANAGER/AGENT _
NO P.O BOX ` /-
ADDRESS �� �1AI_>�S/c ADDRESS_ .
CITY, STATE,ZIP t' 1;?� ,19�f} CITY, STATE,ZIP
RESIDENCE PHONE. �� BUSINESS PHONE(24HRS)
BUSINESS PHONE : r
TOTAL NUMBER OF ROOMS: T
ROOM USE: 1. _. 2. 3. _ 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 AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE _- DATE
Inspectors use only
Date on initial inspection:_ _ Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: DwellingOther Check# Check date: �r2i
Notes:
Code Enforcement inspector