255 Lafayette Street Unit 9 Certificate of Fitness Application 1-9-2020 i
r CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR
SALEM,MA 01970 Prevent,Promote.Protect.
KIlvIBERLEY DRISCOLL TEL. (978) 741-1800health(c�salem.com
MAYOR DAVID GREENBAum
HEALTH AGENT
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: 150.00
PROPERTY LOCATED AT --�5 l a -t t� �-(- UNIT# CI
IF THIS UNIT IS DISIGNATED AS RI T LEFT,FRONT OR BACK.PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES NO
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OWNER/LESSOR . S cl ���j f 1 r e! t(4/I, JMANAGER/AGENT(! InC(r PS r e,e v"a n
NO P.O.BOX A �
ADDRESS A� 5 �GAi C � � L.n k' , -e
CITY, STATE,ZIl' GJ 4 m k CITY, STATE,ZIP
RESIDENCE PHONE y I q _ a q ':�-CI CELL PHONE(24HRS) !$f-) 90'c/--)S l
EMAIL }, 1 t� `� 0 }'}t �, , Lb C7 Yyl
TOTAL NUMBER OF ROOMS:_
ROOM USE: 1. 2, J3. 5
Bedroom#1 ft2 Bedroom#2 a ftZ Bedroom#3 fl 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 IS AT TIME OF INSPECTION
APPLICANT'S SIGNAT- ' DATE
Lc7
Inspectors use only
Date on initial inspection:� 1 a'0 _ Date of reinspection:
Date of issuance of certificate:. Date fee paid: a I d d D
Type of unit: Dwelling _Other Check# I� —Check date: a a-0
Notes:
Code Enforcement Inspector