0000 FEDERAL COURT - Street Files v� �oNo► �
City of oSatem, Ma machusetts CHECK#�v
Fee Due
n — ' Inspection Date:Ins
FIRE DEPARTMENT-FIRE PREVENTION DIVISION p
M.E., 29 Fort Avenue ^�
��/MINBd Salem, Massachusetts 01970-5232 Time l -dJ _
APPLICATION FOR CERTIFICATE OF COMPLIANCE Closing Date:
To: HEAD OF FIRE DEPARTMENT One Family Dwelling
❑ Two Family Dwelling
❑ Condominium Unit#
Application is hereby made for inspection of smoke detectors and carbon monoxide alarms as required by Massachusetts
General Law,Chapter 148 Sections 26F,26F1/2 and 527 CMR 31.et seq.
Type of Smoke Detector Battery Hardwire Hardwire w/Bat. back-up Heat Combination
Type of Carbon Monoxide Detectors Battery Plug-in w/Bat.Back-up Combination
Is 1
Location of Property F_68�G'
Owner of Property r 1 Ck P,4 � � , �*
Date of rtification `����/� Y" ► SG
OWNER OR AGENT
By
PHONE
Note:Any certificate issued in accordance with provisions of M.G.L. Chapter 148 Sections 26F,26F1/2 expires
sixy(60)days after issuance by head of the Fire Department.