19 Hancock Street #1 Certificate of Fitness Application 5-1-2017 Sk
CITY OF SALEM, MASSACHUSE17S
I Bo xRD OF�IE_NLTH
120 WASHINGTON STREET,4m FLOOR
TEL.(978)741-1800
KIM 3F.RLEY DRISCOI I. FAX(978)745-0343
MAYOR LRiUTA;(G_�31 i:�i t]si
LARRY RAMDIN,RS/REHS,CHO,CP-FS
HEALTH.AGFNT
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: S50.00
PROPERTY LOCATED AT t c Harl ccgcI _ '! 4- UNIT#
IS THIS UNIT DISIGN�A"TED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER (Q,a ��wl��1 MANAGER/AGENT
NO P.O.BOX �_ - ^
ADDRESS U+r` X`n r� ADDRESS
CITY,STATE,ZIP- C>Ici CITY,STATE,ZIP
RESIDENCE PHONE_q2L'"l 4I --310-7 a BUSINESS PHONE(24HRS)
BUSINESS PHONE L11. 1 -1 - ;-R-'—S
TOTAL NUMBER OF ROOMS: t
ROOM USE: 1k 2D( 1 3. L 4.ZCA- 5.
6. 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 AT THE TR%4E OF INSPECTION 7 f
APPLICANT'S SIGNATURE _0 DATE 1
Inspectors use only
� ii�
Date on initial inspection: l 7 Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# `7 51-6 Check date: 51 I 11`]
Notes: L 0 wik\d 126 t- ] Cry
Code nfo m'hd Inspector 1