26 Shillaber Street #2 Certificate of Fitness Application 2-15-2018 CITY OF SALEM, MASSACHUSETTS
Qj BOARD OF HEALTH
alth
120 WASHINGTON STREET 4..FLOOR PL1b11CHe.. OW.
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Prevent.Ptomote.Protect.
TEL. (978) 741-1800 FAx(978) 745-0343
KIMBERLEY DRISCOLL kamdin@salem.com
L,-kRItY ILIMDIN,RS/I2I�IIS,,CJ-IO,CP-FS
MAYOR HEALTI-J 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"
tt__ FEE: $50.00
PROPERTY LOCATED AT 0(0 SVl ����-� UNIT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSER ' 6 A C, MANAGER/AGENT_ _
NO P.O. BOX
ADDRESS ii 51± _ADDRESS
CITY, STATE,ZIP CITY, STATE,ZI `
RESIDENCE PHONE SZ���� b -'/,) LBUSINESS PHONE(24HRS)
BUSINESS PHONE
TOTAL NUMBER OF ROOMS: to
ROOM USE: 1. 2. 3. 4. 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 TIME OF INSPECTION
APPLICANT'S SIGNATURE DATE
Inspectors use only
Date on initial inspection: c I�' Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling. Other Check# j �O � Check date: a
Notes:
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Code rc ent Inspector