153 Boston Street Certificate of Fitness Application 3-31-2018 ��5-�J� v�sCJ✓r—
Cl SACHUSE RfS
l r EIVED
'fit i I 4 n'FLOOR
00 APR 0 5 2018
KIMBERLF,Y DRISCOLL 43
MAYOR ?M B CiTY OF SALEM
BOARD OF HEALTH
LARRY RAMll1N,RS/RF.I3S,030,CP-FS D-7�
HEALTH AGENT' ��� l�
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 1 S 3 r)� I UNIT#
IS THIS UNIT DISII ATE D�A,S\RIGHT LEkW OR BACK,PLEASE CIRCLE ONE
OWNER/LESSERA MANAGER/AGENT
NO P.O.BOX
ADDRESS ADDRESS
CYI'Y, STATE,ZIP <SAore-) j ,. O ICA 70 CITY,STATE,ZIP
RESIDENCE PHONE q 119 74q— 69 BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: 1
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 -3 .
Inspectors use only
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling_ _Other Check# Check date:
Notes:
Code Enforcement Inspector