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11 Hawthorne blvdCASH CHECK# C�Cit Of %lens, ma's"*MMS Fee Due $10.00 per unit FIRE DEPARTMENT - FIRE PREVENTION DIVISION 29 Fort Avenue Salem, Massachusetts 01970-5232 F APPLICATION FOR CERTIFICATE OF COMPLIANCE . FILE COPY ❑ One Family Dwelling To: HEAD OF FIRE DEPARTMENT 'Two Family Dwelling ❑ Condominium Unit #_ Inspection date: ///is%7 Time: © C/ ®d In accordance with the provisions of Chapter 148, G.L. as provided in Section 26E and/or 26F application is hereby made For an inspection of smoke detectors installed per Salem Fire Prevention Regulations The under- signed owner of record or authorized agent, requests the issuance of a Certificate of Compliance for Type of Detectors: A. Monitored Battery Units B. Permanently Wired Units Owner: Address: (Give location by street and number, or describe in such a manner as to provide adequate identification of location) LIST LOCATION OF DETECTORS ON BACK OF APPLICATION Real Estate Agent Date of Certification: (Address) By: (Phone) Layout of Smoke/Heat Detectors: Basement: 1st Floor: 2nd Floor fi rt 3rd Floor: Special Requirements: