1 Forrester Street Certificate of Fitness Application 11-14-2019 � y`; SSACHUSEITS CITY OF SALEM, MA
BOARD oF HEALTH.
98 WAST-UNGTON STREET,3RD FLOOR PaficHedth
SALEM,NL-k 01970 Prevent.Promote.Protect.
KTNIBERLEY DRISCOLL TEm. �)-/8) 741-1800
heallh@salem.com DA.V it.)GR.1s._1-..NBAUM
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Application for Certificate of Fitness
IN ACCORDANCE WITH CITY OF SALEM ORDINANCE, SEC. 2-705
"CERTIFICATE OF FITNESS OF RENTED DWELLING UNIT, APARTMENT OR TENEMENT"
FOR COMPLIANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00 f 6-8'�
PROPERTY LOCATED AT 1 Forrester St. UNIT#
IF THIS UNIT IS DISIGNATED AS RIGHT,LEFT,FRONT OR BACK,PLEASE CIRCLE ONE
IS THIS UNIT BEING RENTED AS A SHORT-TERM RENTAL? YES X NO
OWNER/LESSOR Jennifer Geraghty MANAGER/AGENT
NO P.O.BOX
ADDRESS I Forrester St. ADDRESS
CITY, STATE,ZIP Salem, MA CITY, STATE,ZIP
RESIDENCE PHONE. (617)869-4870 CELL PHONE(24HRS)— (617) 869-4870
EMAIL- theivesinn(a-)jZmail.com
TOTAL NUMBER OF ROOMS: 3
ROOM USE: 1. bedroom 2. bedroom 3. be room 4. 5.
Bedroom#1 144 ft2 Bedroom#2 200 ft2 Bedroom#3 156 ft2 Bedroom#4 ft2
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 10i
0 6
Inspectors use only
Date on initial inspection: f Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# (C�5 Check date:
Notes:
Code Enforcement Inspector 41&-
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