3 1/2 BECKET AVENUE, #3 CERTIFICATE OF FITNESS APPLICATION 2-8-2018 RECEIVED 02/08/2018 02:29PM 9787450343 Salem Health Dept
From:GBRB SALEM 978 745 5706 02/08/2018 14:25 #311 P.001/001
CITY OF S_ALEM, INIASSACH USETTS
BoARI.)0FHE.A1.T11
."120 WASI 1INGT02'N S'1'1,j a'-1 T,4 R
'I-j_ij_ (978) 741-1800
(978)7450343
LARRYIZ_ MDIN,RS/1',J]IS,Cl 10,
4-1 ao j) 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 6f % --c V) - 141 VP1% UN IT#
IS THIS UNIT DISIGNATED AS RIGHT LEFT FRO T OR BACK,PLEAS-CIRCLE ONE
OWNER/LESSER A -vijj�21�M4 MANAGER/'AGE
NO P.O.BOX , - ( I ADDRESS 'I ,
ADDRESS US V Jea� S /,x C;h V,&_qeex, S
CITY,STATE,ZIP btl,U �W N —CITY,STATE,ZIP S chi V-P yq /0
RESIDENCE PHONE BUSINESS PHONE(24HRS)
BUSINESS PHONEC �3 i (0
TOTAL NUMBER OF ROOMS:
ROOMUSE: 1. 6VJn� 2. Ifc. 3, 4. lsee4,00m 5 Re
6. U 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 HE TIME OF INSPECTION
APPLICANT'S SIGNAT,�,,_,_,,,� 'a) DATE
TIns L use only
Date on initial inspection: Date of reinspection:
Date of issuance of certificate: Date fee paid:
Type of unit: Dwelling OtherCheck# Check date:
Notes:
Code Enforcement Inspector