6 GLENDALE STREET, UNIT 2 - CERTIFICATE OF FITNESS APPLICATION a k) CITY OF SALEM, M.ASS.ACHUSETTS
xy BOAItn OF HF�tr.rll
x�f 120 WASHINGiTON S 1 121=.1?;I',4""FLOOR
TrL. (978) 741-1800
KIMBERLEY DRISCOLL FAx(978)745-0343
MAYOR t�+;hlri IN&AL1.0vil"(W
L im,RAMDIN,RS/RF:T-TS,CT-TO,CT'-hS
HEAL:rn 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 r UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER Marie Gagnon -MANAGER/AGENT
NO P.O.BOX —-
ADDRESS 8 Cteary Lane ADDRESS
CITY,STATE,zip_Topsfield, Ma 01983 —CITY,STATE,ZIP _ _
RESIDENCEPIIONE 978-887-8856 _BUSINESS PHONE(24HRS)-
13USINESS PHONE 978-887-8856
TOTAL NUMBER OF ROOMS: S_
ROOM USE: 1._1' _ 2. tr—3'; 4. ►
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 TIME OF INSPECTION
APPLICANT'S SIGNA` L J R-F DATE
In. ectors use only
Date on initial inspection: Date of reinspection;
Date of issuance of certificate:_ Date fee paid:
Type of unit: Dwelling Other Check#_ �l Check date:-
Notes;
J�C ��✓
Code hnf ent Inspector