39 Prince Street Certificate of Fitness Application 2-8-2018 TEL- (,9.1K, i11-1800
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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 Py-t _ `. UNIT# 3
IS Ti MS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BA( PLEASE CIRCLE ONE
OWNER/LESSER rAe-wa rrA L L c- MANAGER/AGENT L,�0, �-
NO P.O.BOX
ADDRESS 51 ADDRESS
CITY,STATE,ZIP 0 b)tw vx, A- c�t $'y) CITY,STATE,ZIP
RESIDENCE PHONE l r�3 a --5 3`� BUSINESS PHONE(24HRS) t
BUSINESS PHONE
TOTAL NUMBER OF ROOMS:
ROOM USE: 1. 6 eat 2. &ek 3. R—ZA 4. 5.
6.A--%%w 7. jAtAL vx 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 TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE
Inspectors use only
Date on initial inspection: (� g Date of reinspection:
Date of issuance of certificate: Date fee paid: IR
Type of unit: Dwellin�_ Other Check#`-'7 Check date: 'zk tv--
Notes:
Code E'Wraiifnent Inspector