44 Prince Street Certificate of Fitness Application 2-9-2018 RECEIVED 02/11/2018 09:33PM 9787450343 Salem Health Dept
Feb.11.2018 10:33 Am 7815950322 PAGE. 1/
C"ITY ()FSAL.FN1, MASSACI 1USP'TTS
BOARD OF'14FAINI I
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Application for Certificate of Fitness
IN ACCORDANCE WITH STATE SANITARY CODE,CHAPTER It, 105 CMR 410.000
"MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION"
PROPERTY LOCATED AT Lz1rJC UNITW-�
IS THIS UNIT DISIGNATEI)AS RIGHT LEFT FRONT OR BACK,PLEASE CIRCLE ONE
OWNER/LESSERO 0ne-� Z&0Vj[1(1,rMANA0jER/ACyENT
NO P.O.DOX ' cad.'-) 0-(lenv
ADDRESS,SQ ADDRESS 2%,-P-VSt1fj.5L . 11
t
CITY,STATE,ZIP SWftX--�P-S LLA4 , H(l CITY,STATE,ZIP riv C)
RESIDENCE PHONE BUSINESS PHONE(24HRS)
BUSINESS PHON-E-83A96e- CLAI lfr- 71 SL ee, ,
TOTAL NUMBER OF ROOMS: - Aviv%4-W)0-
ROOM USE: 1, L.ty-,koj 2. 4-e- br 3. 6&'�i o,7 4. Ae4m&�, 5. Be rocr-)
6. Ljzj- , 7, .9. 9. jfk.
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 DATC
inspectors use qnl�+
Data on initial inspection: Daw of reinspoction-,
Date of issuance of certificate: Date fee paid,
Type of unit: Dwelling-Other Check 0 Check date;.______
Notes:
Code Enfor(;enient Inspector