2 CHASE STREET, UNIT 3 - CERTIFICATE OF FITNESS APPLICATION CITY OF SALEM, MASS.ACHUSETTS
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120 WASHINGTON S i-wI,I.x,4""Flom
Tr_.L. (978) 741-1800
KIMBERLEY DRISCOLL FAX(978)745-0343
MAYOR I.a�1,anlratC7.yf�I;rjna:t c»tir
LA]IRY R A MD1N,(6/kE.1-IS,(:ir(7,C11-I.S
FIRALTI-I 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 " " UNIT#, _7,
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LFS.ER Marie Gagnon MANAGER/AGENT
NO P.O.BOX
ADDRESS 8 Cleary Lane _ An
CITY,STATE,ZIP Topsfield, Ma 01983 CITY,STATE,ZIP
RESIDENCE PHONE 978-887-8856 BUSINESS PHONE(24HRS)
BUSINESS PHONi.G78-887-8856
TOTAL NUMBER OF ROOMS:- _L—.
ROOM USE: 1. 2 L.M vs+,�4—; 4, 5.
6: 7. 8. 9.
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 Y Zca
Inspectors rase only
r.
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other _ Check# 1� S� Check date:3
Notes:
A _
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Code EnM ce6'nt Inspector _I `�