12 Pope Street #B403 Certificate of Fitness Application 2-8-2018 CITY OF SALEM, MASSACHUSET-fS
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� IiC:).11RD OF HE;AT.I'I'i
120 WASHINGTON STR}3ET,4"'FLOOR
TEL. (978) 741-1800
ICNIB 'RLEY DRISCOLL F kX(978)745-0343
MAYOR r.rt�.nlr�rrvQa,5 n�a:;m.canr
LARR.Y RAMIDIN,RS/RVI IS,(110,(;;13-1:S
I-AL1'11 A(� ,I±NT
Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITAIZY CODE, CHAPTER 11, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
FEE: $50.00
PROPERTY LOCATED AT Roped `'�
_ s � b-6 UNIT#_ A6-�rD
IS TH DI GNAT .D A RIGHT LEFT FRONT R BACK,PLEASE C L ONE
OWNER/LE SER _MANAGER/AGENT
NO I'.O, BOX
ADDRESS Z— e S /C-0� ADDRESS
CITY, STAT, ,ZIP CITY, STATE,ZIP_
RESIDENCII PHONE BUSINESS PHONE(24HRS)
BUSINESS ONE ( -�
TOTAL M
BER OF ROOMS:
ROOM USE: 1. 4 4
6. 7. ^9. 10.
THERE IS A FIFTY($50)DOLLAR FE AY ABLE BY CHECK OR MOON ORDER TO THE CITY OF SALEM
BOARD OF HEALTH THI5 FEE IS P LE THE TIME OF INSP ION /
APPLICANT S SIGNATURE - —DATE-
Inspectors,use only
Date on initial inspection: ) �_ Date of reinspection:_ __
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling Other Check# Check date:
Notes:--
Codet'nfo)x1cm t Inspector
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