6 GLENDALE STREET, UNIT 1 - CERTIFICATE OF FITNESS APPLICATION • CITY OF SALEM, M.ASSACHUSETTS
BOARD 01-111?A]MI-1
120 WA ST-TINGTON S"L'tt.t,t T,4"'M ooit
TBj.(978)741-1800
KIMBERLEY DRISCOLL Fnx(978)745-0343
MAYOR 1.Ti,�n�nft�snllfTs:'��r
LAIM,RANIMN,12S/1ZFT-TS,CT-TO,Ci'-hS
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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#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWMM—ESSER Marie Gagnon --MANAGER/AGENT
NO P.O.BOX
ADDRESS_8 Clea Lane _ ADDRESS
CITY, STATE,ZIP Topsfield, Ma 01983 CITY,STATE,ZIP
RESIDENCE PRONE 978-$$7-8856 BUSINESS PHONE(24HRS)
BUSINESS PHONE -978-887-8856
TOTAL NUMBER OF ROOMS:
ROOM USE: "r4x -`s' 2 txb 3 1 4: 5. rr
6. 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 31z c\Vb
ospeetnrs u e.only
Date on initial inspection; L[ Date of reinspectionr
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling -Other Check# 107 _Check dater
Notes:
Code 6 Inspector