5 Wall Street Certificate of Fitness Application 12-28-2017 r
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{ CITY OF SAIJEM, Mr1SSACHUSEI'TS 10
BOARD OF H E 1LTH ���'=
120 WASHINGTON STREET,4r}'FLOOR Prevent.
TEL. (978) 741-1800 F_-�t(978) 745-0343
KIMBERLEY DRISCOLL Iramdin@salem.com
L,\RRY R;\MDIN,RS/12F,I-IS,CHO,Cl'-FS
MAYOR HE;11:,T1-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 V1/a I UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER I-Y, % JCA- MANAGER/AGENT_
NO P.O.BOX
ADDRESS OL ADDRESS
CITY, STATE,ZIP CI O CITY, STATE,ZIP
RESIDENCE PHONE_776� a`Sl�--a��� BUSINESS PHONE(24HRS)
BUSINESS PHONE_
TOTAL NUMBER OF ROOMS: I
ROOMUSE: LV)E1-ftm 2. L N%1r0 �m3. V'�Aer\ 4. W(Ce_ 5.
6. 7. 8. 9. 10.
THERE IS A FIFTY($50)DOLLAR FF,4,PAYABLE BY CHECK OR MONEY ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THIS FEE IS P ABLE AT THE TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE I a J
f Inspectors use only
Date on initial inspection:, 7 Date of reinspection:
Date of issuance of certificate: Date fee paid: 1 a I
Type of 't: Dwelling Other Check# ��c'l Check date:
Notes: m It [ car')di^
Code went Inspector