HORTON STREET City of Salem, Massachusetts
Board of Health
120 Washington Street, 4th Floor, Salem, P,<.ent. �,��„
MA 01970
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS, CHo
Mayor health@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE#: GHL-16.345
DATE ISSUED: 9/8/2016
Property Located at: 16 HORTON STREET UNIT#2
Owner/Agent: Michele Barling
Address: 16 Horton Street
City/Town: Salem, MA Zip Code: 01970 24 Hour Phone:(978) 210-4494
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division 3, Section 705: Certificate of fitness of
rented dwelling unit, apartment or tenement. An inspection of your vacant Dwelling/Rooming Unit at the above address has
been approved and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II "Minimum
Standards of Fitness for Human Habitation'.
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of Health and the unit may now
be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
Note: This approval does not certify compliance with the state lead law for occupants under 6 years of age.
s
Larry Ramdin, MPH, REHS, CHO
HEALTH AGENT SANITARIA
CITY OF SALEM, (MASSACHUSETTS
;i BOARD OF HEALTH
5� 120 WASHINGTON STREET,4"FLOOR
TEL. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978) 745-0343
MAYOR iRAmDrNngsA Fm.coM
LARRY RAibIDIN,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 0 H'0?1 6 T, SA I.EM M A UNIT#
IS THIS UNIT DISIGQNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER M I� �. LJA� a tJG MANAGER/AGENT (5ftVE (q5
NO P.O.BOX y,
ADDRESS O P 1 D K-ro 6T ADDRESS
CITY, STATE,ZIP gALCrn I + nA 1 o CITY,STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS)
BUSINESS PHONE q )t 110 -`f`I-9�'
TOTAL NUMBER OF ROOMS: /
ROOM USE: 1. bG�mn 2. 609COO`3. ^.4. ft900A 5. VA-rCrtc—n7
6. L.,V6 NG 20 7. ynfl . 9. 10.
THERE IS A FIFTY($50)DOLLAR FEE,PAYABLE BY CHECK OR MONEY ORDER TO T14E CITY OF SALEM
BOARD OF HEALTH THIS FEE IS PAYABLE AT THE TIME OF INSPECTION Q
APPLICANT'S SIGNATURE /'/ L�'�� DATE
Inspectors use only
Date on initial inspection: r)qla?-Oi6 Date of reinspection:
Date of issuance of certificate 0 l�� Date fee paid: �n �,
Type of unit: Dwelling V Other Check#—I,&Check date: JDI�2X 2pl�
Notes:
Eq:orcement ector
City of Salem, Massachusetts
Board of Health
m 120 Washington Street, 4th Floor, Salem, PablicHealth
MA01970 Prevent. Promote. Protect.
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, REHS, CHO
Mayor Iramdin@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE #: GHL-16-189
DATE ISSUED: 5/27/2016
Property Located at: 6 HORTON STREET UNIT#1
Owner/Agent: Nicole Bouchard
Address: 20 Pierce Road
City/Town: Lynn, MA Zip Code: 24 Hour Phone:(781) 267-6121
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division 3, Section 705: Certificate of fitness of
rented dwelling unit, apartment or tenement. An inspection of your vacant Dwelling/Rooming Unit at the above address has
been approved and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II "Minimum
Standards of Fitness for Human Habitation'.
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of Health and the unit may now
be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
FOR THE BOARD OF HEALTH
Larry Ramdin, MPH, REHS, CHO
HEALTH AGENT SANITARIAN
CITY OF SALEM, MASSACHUSETTS V
BOARD of HEALTH
120 WASHINGTON STREET,4'"FLOOR r... I
TEL. (978)741-1800 FAX(978)745-0343
KWBERLEY DRISCOLL Iramdin@saLe-m—.com LARRY RAMI)IN,RS/RENS,C1iO,CP-F'
MAYOR HEAL731 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"
FLEE: $50.
L� 00
PROPERTY LOCATED AT �� l�o ri 0v'yn J e e UNIT#_-L
IS THIS UNIT DISIGNATED AS EIS FRONT OR SACK PLEASE CIRCLE ONE
OWNER/LESSER 6( 2�LLC. -vxl MANAGER/AGENT
NO P.O. BOX pp
ADDRESS .A 0 �@ L4 ADDRESS
CITY, STATE,ZIP CITY,STATE ZIP��
RESIDENCE PHONE Z BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: n
ROOM USE: . XZ_ 1M2 BDR�3�D ISM 4. LL\A'M 5.
6 7 8 9. 1 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 l I� n/� �-� �\ DATE * (z
Inspectors use only
Date on initial inspection:0 57/Z y2 D r,6 Date of reinspection:
Date of issuance of certificate: S 2016 Date fee paid: n W23/20.Z�
Type of unit: Dwellin Other Check#Check date: 05
Notes:
C /9,11ment.1,dpector
CERT.# 329-97
3 FEE $25.00
DATE: 05/28/97
l'
MRB
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tel:(506)741-1800
Fax:(508)740-9705
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 4 Horton Street UNIT #: 1st floor
OWNER/AGENT: Jemay Realty Trust c/o Marie Thibault
ADDRESS: 7 Louis Road
CITY/TOWN: Danvers, MA ZIP CODE: 01923 24 HOUR PHONE: 774-4134
AN INSPECTION OF YOUR VACANT DWELLING/ROOMING UNIT AT THE ABOVE ADDRESS HAS
BEEN APPROVED AND IS IN COMPLIANCE WITH 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
THEREFORE, THIS CERTIFICATE IS ISSUED BY THE CODE ENFORCEMENT DIVISION OF THE
SALEM HEALTH DEPARTMENT AND THE UNIT MAY NOW BE RENTED AND/OR OCCUPIED.
MAXIMUM NUMBER OF OCCUPANTS, BASED ON 105 CMR 410.000 : MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
SECTION 410.400 (B) : DWELLING UNIT (X) AND 410.400 (C) : ROOMING UNIT
MINIMUM SQUARE FOOTAGE FOR SLEEPING PURPOSES: .
NOTE: THIS APPROVAL DOES NOT CERTIFY COMPLIANCE WITH THE STATE LEAD LAW FOR
OCCUPANTS UNDER 6 YEARS OF AGE.
FOR THE BOARDOFiA 44 ",
a
JOANNE SCOTT, MPH,RS,CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
a
3 yz
CITY OF SALEM BOARD OF HEALTH
Salem, Massachusetts 01970-3928
JOANNE SCOTT,MPH,RS,CHO NINE NORTH STREET
HEALTH AGENT Tei:(508)741-1800
APPLICATION FOR CERTIFICTE OF FITNESS Fax:(508)740-9705
IN ACCORDANCE WITH STATE SANITARY CODE, .CHAPTER II, 105 CMR 410.000 "MINIMUM
STANDARDS OF FITNESS FOR HUMAN HABITATION".
PROPERTY LOCATED AT `J UNIT /
OWNER/LESSER pN � J MANAGER/AGENT- /Y�Cz,4- t F,
ADDRESS ADDRESS ri a_
CITY CITY
RESIDENCE PHONE BUSINESS PHONE (24 HRS.) 509'-77L/-y/3{(
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1.
5. 5. 7. 8. —THEREISIS A TWENTY-FIVE (25.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY ORDER TO THE
CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE TIME OF INSPECTION
APPLICANTS SIGNATURE �� l^CGLc e_.- CJ c+ Kx1 DATE ?19 --
INSPECTORS USE ONLY
DATE OF INITIAL LNSPECTICN: —eDA'I'S OF REINSPECTION —
DATE OF ISSUANCE OF CERTIFICATE: DATE FEE PAID:y _
TYPE OF UNIT: DWELLING OTHER _
NOTES :
CODE ENFORCEMENT INSPECTOR
CITY OF SALEM, MASSACHUSETTS
o m BOARD OF HEALTH
a 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
W W W.SALEM.COM
Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO
Mayor HEALTH AGENT
CERTIFICATE OF FITNESS
CERTIFICATE#563-06
DATE ISSUED: 11/13/2006
Property Located at: 6 Horton Street UNIT# 1'
Owner/Agent: Nicole Bouchard
Address: 20 Pierce Road
City/Town: Lynn, MA Zip Code: 01902 24 Hour Phone: 434-5191
An inspection of your vacant Dwelling/Rooming Unit at the above address has been approved
and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II"
Minimum Standards of Fitness for Human Habitation".
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of
Health and the unit may now be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates,whichever
is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
FOR THE BOARD OF HEALTH
�J
JOA OtNE SCOTT, MPH, RS, CHO
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
e CffY OF SALEM, wsS ActiusEws
BOARD HEALTH
STREET,
+ �7o
120 WASHINGTON STREET, 4TH FLOOR (fQ_ f
SALEM, MA 01970
TEL. 979-741-1800
FAX 978-745-0343 -
JOANNE SCOTT, MPH, RS, CHO -
Kimberley Driscoll HEALTH AGENT
Mayor
APPLICATION FOR CERTIFICATE OF FITNESS
IN ACCORDANCE WITH STATE SANITARY CODE,CHAPTER It, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HALBiTATiONO, {
PROPERTY LOCATED AT ov� S ? ! __.__UNIT a__�
IS THIS UNIT DESIGNATED ASI?� G4HT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER.. i C ;hiu,c LtiIrck MANAGER/AGENT_
No P.O. Box NO P.O.Box
ADDRESS,= P�C .M.-Cz_, � ADDRESS_ _
CITY— L_ v-,3IV V\A ft —CITY--
RESIDENCE
ITYRESIDENCE PHONE_—__„ —_BUSINESSPHONE (24 HRS)t] tL�_-0'2.(e�—(p
BUSINESS PHONE
I TOTAL NUMBER OF ROOMS:._._
II
ROOM USE: 1.._L,V _2.l{ s. � .__g� ry�
THERE IS A TWENTY-FIVE ($25.00) DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE
TIME OF INSPECTION. Q //
APPLICANTS SIGNATURE ---� :` ` ._ DATE-
INSPECTORS USE ONLY t 1
DATE OF INITIAL tNSPECT)ON_-//-/ - 49_10__ PATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE//-j? -0 4 DATE FEE PAID _/, .
TYPE OF UNIT: DWELLINI f OTHER _ CHECK If T Y'r5� CHECK DATE
NOTES.__ _. \ .
CODE ENFORCEMENT INSPECTOR 9/28/98
pONDlq,,
City of Salem, Massachusettslu
� . _
Board of Health
120 Washington Street, 4th Floor, Salem, PablicHealth
'y F. Prevent. Promote. Protect.
MA 01970
Kimberley Driscoll Tel. (978) 741-1800 Fax. (978) 745-0343 Larry Ramdin, MPH, RENS, CHO
Mayor Iramdin@salem.com Health Agent
CERTIFICATE OF FITNESS
CERTIFICATE #: GHL-15-25
DATE ISSUED: 4/16/2015
Property Located at: 6 HORTON STREET UNIT#2
Owner/Agent: Nicole Bouchard
Address: 20 Pierce Road
City/Town: Lynn, MA Zip Code: 24 Hour Phone:(781) 267-6121
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division 3, Section 705: Certificate of fitness of
rented dwelling unit, apartment or tenement. An inspection of your vacant Dwelling/Rooming Unit at the above address has
been approved and is in compliance with 105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II "Minimum
Standards of Fitness for Human Habitation'.
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of Health and the unit may now
be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
FOR THE BOARD OF HEALTH
0,—�� A-4'1�'k
Larry Ramdin, MPH, REHS, CHO
HEALTH AGENT SANITARIAN
CITY OF SALEM, MASSACHUSETTS
r _ .
BOARD OF HEALTH
—' 120 WASHINGTON STREET,4."FLOOR
TEL. (978)741-1800
KIMBERLEY DRISCOLL FAA(978) 745-0343
MAYOR LRAM v eM cona
Lmw RAMDIN,RS/RW IS,C:FIO,0 J S
HE;\l.'1'H AGFsN'1' c� +�
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
c FEE: $50.00
Ca
PROPERTY LOCATED AT 44c*r Tw >' re e � � � 1
IS THIS UNIIT-DIISSI_GNATED AS RIGHT LEFT FRONT OR BACK.PLEASE CIRCLE ONE
OWNER/LESSER y 1.1 ` r n 1-3t5tt S_�w'�ANAGER/AGENT
NO P.O.BOX
ADDRESS ! <- b ADDRESS --
CITY,STATE,ZIP .,{' ) CITY,STATE,ZIl' LT /
RESIDENCE PHO ' 1 �—��BUSINESS PHONE(zaHRs)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: S
ROOM USE: 1 2. 3. 4. 5.
6. 7. B. 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
A 'PLICANT'S SIGNATUREf
1 IMectors use orjx
Date on initial inspection: 1S Date of reinspection:
Date of issuance of certificate: ' } S Date fee paid:
Type of unit: Dwellings,,/ Other Check# -2 1 Check date: k1-hw i V
Notes:
e Enforcement Inspector
r k CITY OF SALEM, MASSACHUSETTS lu
BOARD OF HEALTH
120 WASHINGTON STREET,4"'FLOOR
PliblicHC81Yh
Prevent.PmmaR.Protect.
TEL. (978)741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL Iratndin@salcin.com
LlVZ)LY RAMDIN,RS/1tEHS,C.Hn,Cl I S
MAYOR HEALTH AGI'.NT
CERTIFICATE OF FITNESS
CERTIFICATE#205-13
DATE ISSUED: 6/14/2013
Property Located at: 6 Horton Street UNIT#3
Owner/Agent: Nicole Bouchard
Address: 20 Pierce Road
City/Town: Lynn, MA Zip Code: 01902 24 Hour Phone:
Pursuant to the requirements of City of Salem ordinance Chapter 2 Article IV Division3, Section
705: Certificate of fitness of rented dwelling unit, apartment or tenement. An inspection of your
vacant Dwelling/Rooming Unit at the above address has been approved and is in compliance with
105 CMR 410.000: Massachusetts State Sanitary Code, Chapter II"Minimum Standards of
Fitness for Human Habitation".
Therefore, this Certificate is issued by the Code Enforcement Division of the Salem Board of
Health and the unit may now be rented and/or occupied.
Maximum Number of occupants, must comply with 105 CMR 410.000.
Certificate valid for one year from date of issuance or until the current tenant vacates, whichever
is later.
This Certificate of Fitness is valid only if there is a valid Certificate of Occupancy.
FOR THE BOARD OF HEALTH
LARRY RAMDIN
HEALTH AGENT AN
�✓P
CITY OF SALEM, MASSACHUSETTS � .
BOARD OF HEALTH .
120 WASHINGTON STREET,4T"FLOOR PubHc'mH.vea
TEL..(978)741-1800 FAX(978)745-0343
KIMBERLEY DRISCOLL lramdinRa salem.com
MAYOR LARRY RANMIN,RS/RF.HS,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 L -` - , 5 PrLe rn UNIT#�
`_IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK PLEASE CIRCLE ONE
OWNER/LESSER 1 \ 0 e- o MANAGER/AGENT
C l 6 C"-
NO P.O..BOX
ADDRESS Lo �t�e-y'G�2 , Q\ ^_ ADDRESS
CITY,STATE,ZIP L lU A) �/ Y �_ CITY, STATE,
RESIDENCE PHONE .7" -Co Z BUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: 1�
ROOM USE: 1. IV VA, 3. )6% t' 4. i It
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��
Inspectors use only
Date on initial inspection: Date of reinspection
Date of issuance of certifi Date fee paid:
Type of unit: DwellingOther Check#Check date:
Notes:
Code orcement Inspector
cu CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
3 120 WASHINGTON STREET, 4TH FLOOR CERT.# 3-02
�-a 1 SALEM, MA 01970 FEE $25.00
TEL. 978-741-1800 DATE: 01/03/2002
FAX 978-745-0343
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
i
CERTIFICATE OF FITNESS
PROPERTY LOCATED AT: 16 Horton Street UNIT #: 1
OWNER/AGENT: Michele Barling
ADDRESS: 16 Horton Street
CITY/TOWN: Salem, MA ZIP CODE: 01970 24 HOUR PHONE: 745-7066
AN INSPECTION OF YOUR VACANT DWELLING/ROOMING UNIT AT THE ABOVE ADDRESS HAS
BEEN APPROVED AND IS IN COMPLIANCE WITH 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
THEREFORE, THIS CERTIFICATE IS ISSUED BY THE CODE ENFORCEMENT DIVISION OF THE
SALEM BOARD OF HEALTH AND THE UNIT MAY NOW BE RENTED AND/OR OCCUPIED.
MAXIMUM NUMBER OF OCCUPANTS, BASED ON 105 CMR 410.000: MASSACHUSETTS STATE
SANITARY CODE, CHAPTER II, "MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION" .
SECTION 410.400 (B) : DWELLING UNIT (X) AND 410.400 (C) : ROOMING UNIT
MINIMUM SQUARE FOOTAGE FOR SLEEPING PURPOSES: .
NOTE: THIS APPROVAL DOES NOT CERTIFY COMPLIANCE WITH THE STATE LEAD LAW FOR
OCCUPANTS UNDER 6 YEARS OF AGE. FOR MORE INFORMATION CALL 978-741-1800.
FOR THE BOARD OF
OFHEALTH
U JOANNE SCOTT, MPH,RS,CHO �
HEALTH AGENT CODE ENFORCEMENT INSPECTOR
I
i
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
♦ 5 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343,
STANLEY USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
APPLICATION FOR CERTIFICATE OF FITNESS
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS F,OLR� HUMAN HABITATION".
PROPERTY LOCATED AT,IG n -'ter"� 5-F UNIT#
IS THIS UNIT DESIGNATED AS RIGHT LEFT FRONT BACK PLEASE CIRCLE ONE
OWNER/LESSER IAICHOk IT�MANAGER/AGENT ._
No P.O. Box Tom S` No P.O. Box
ADDRESS �� ;" ADDRESS_._.
CITY 5kLei-y-\ IY>F't p1gZ0 CITY
RESIDENCE PHONEq 1'6--7 FS"-7t''L-JA-USINESS PHONE (24
BUSINESS PHONEGn-6c q-5oto x 103
TOTAL NUMBER OF ROOMS:
ROOM USE: 1.� �G 2. 8.�' 4 r _
5.7 6. 7. 8.
C�.
THERE IS A TWENTY-FIVE($25.00)DOLLAR FEE, PAYABLE BY CHECK OR MONEY
ORDER TO THE CITY OF SALEM HEALTH DEPARTMENT THIS FEE IS PAYABLE AT THE
TIME OF INSPECTION.
APPLICANTS SIGNATURE Olt CR-0-' _DATE 1 -3-09
L $ECTORUSE Y
ONL
DATE OF INITIAL INSPECTION/ - 3 --0 -'Z— DATE OF REINSPECTION
DATE OF ISSUANCE OF CERTIFICATE: -3 `z 2-- DATE FEE PAID:`3 ti
TYPE OF UNIT: DWELLING(OTHER_ CHECK# ?� D CHECK DATE 3-6
NOTES: `/l\
CODE ENFORCEMENT INSPECTOR 9/28/96