12 Pope Street #B110 Certificate of Fitness Application 5-4-2017 q.
CITY OF SALEM, WSSACHUSETTS
BOARD OF HEALTH
120 WZVSHINGTON STpj-,-E-T,4:7"FLOOR
KT'M-BF,IRI,J:!',Y.DRTSCOLI',, FAx(978) 745-0343
MAY.'OR JAAMI QS,'jWW1X:(-W1
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Application for Cerdflcate ®f 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 1 2 Pj,) ,e S uNIT4 /5
IS WIS UNIT DISIGNATEDfAS RIGHT LEFT FRONT OR BACK4 PLEASE CIRCLE ONE
OWNER/LESSER 110" MANAGER/AGENT
NO P.O.BOX ')-e � J .
ADDRESS ADDRESS
CITY, STATE,ZIP. S C� —CITY, STATE,ZIP
RESIDENCE PHONE — BUSINESS PHONE(24HRS)
7 0
BUSINESS PHONE 3 ,7--
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 641V/1 2.
6. 7. 8. 9. 10.
THERE IS A FIFTY($50)DOLLAR FEE,PAYA-BLE BY CHECK OR NEY ORDER TO THE CITY OF SALEM
HE
BOARD OF HEALTH THIS FEE IS P7 L AT THE TIME OF ECTION
APPLICANT'S SIGNATURE DATE
Inspectors use only
Date on initial inspection: 5 [1A Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling` Other Check# Check date;
Notes:
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Code E em_ Inspector - I
CITY OF SALEM, MASSACHUSETTS
B(.)ARD OF HEcILTH
120 WASHINGTON STREET,4f"FLOOR
--TPr,—. (978) 741-f800
KTN1BERLF.',Y DIUSC011, FA-,,,,(978) 745-0343
MAYOIR ]RAKI I N9,111LIm.com
T,Aiz,m,R,1Nfl)[N,IZS/11-Fll fs,CI CO,
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE, CHAPTER 11, 105 CMR4410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
?_ FEE: $50.00
PROPERTY LOCATED AT /)0 e-- E4Xe� UNITI 90;Z-
IS TBAS UNIT DISIGNATED RIPT"T LEFT FRONT ORBACK,PLEASE CIRCLE ONE
OWNER/LESSERt-'O A—t—( MANAGER/AGENT_,
NO P.O.BOX
ADDRESS ADDRESS
CITY, STATE,ZIP —CITY, STATE,ZIP
RESIDENCE PHONE BUSINESS PHONE(24HRS
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: I.ObVr 2. dC
6. 7. 8. 9 10.
THERE IS A FIFTY($50)DOLLAR FEE, YABLE BY CHEC OR MONEY ORDER TO THE CITY OF SALEM
I
BOARD OF HEALTH THIS FEE IS Pr� LE AT THE T IFF INSPECTION
�t-t�
APPLICANT'S SIGNATURE DATE
Inspectors use only
Date on initial inspection: 5 Date of reffispection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# Check date:
Notes:
Code tnfW69 13pector