ABAN/FORCL PROP REG FORM CITY OF SALEM
BUILDING DEPARTMENT
120 Washington Street, 3rd Floor, Salem, MA 01970
ABANDONED AND FORECLOSED PROPERTIES REGISTRATION FORM
PROPERTY INFORMATION z�
Address: 3ci `sale 01 S+ Parcel ID #
Square Footage of Building: 3 39C Number of Stories: 3
Sprinkler System: Yes_NoOperational yes/no)
Pipe System: Yes_ No Operational yes/no)
Fire Detection System: Yes '/No_(Operational yes/no) U r\k_Yla W/)
OWNER(S) * OF RECORD (*attach additional sheets if necessary)
Owner: C-/ T &W ,Jft
Address: 95 N. fq,r 0' TIVZ 7-Pf 1)K. fcclencq, cA 9/1a3
Telephone: 15:3-- Y(oo? -d&j e; E-mail:
CONTACT PERSON/REGISTERED PROPERTY MANAGER
Name: C-Ti SSi CO (ShC r►lari e��
Primary Address (No P.O. Box) Say I'Y'1O r Si- A 1o7 wfr'r►'►i✓t� , rn/I O) kk?
Business Tel. #: '7 )r-isn). - E--o? Non-Business Tel. #: 9)k-Y8- 51a g2
E-Mail Address: f\e_Uje Ajcvitrire cut C,�m
Emergency Telephone #- 24hr/day +r - D ?'
IS THE PROPERTY LISTED FOR SALE? Yes No
If yes, Real Estate Agency '12 MAC en(r)f .
Address: 8On1.Q Cti G49tVsr Tel. No. 9,e?- qied- 6a?8
VACANT BUILDING PLAN: Please check which applies.
1. ;he building is to be demolished.
2. The building is to remain vacant.
3. The building is to be returned to apt opriate cc ancy or use.
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SIGNATURE OF OWNER/OWNER'S AGENT:
DATE: J "Si 0,2 Z it IN
Ck 7
REGISTRATION FEE $300 ___.__ Cash/Money Order/Cert. Bank Check