Cert of Compliance 61 c4_
Citp of *altm, Baaac buott Fee Due $10.00 per unit
FIRE DEPARTMENT-FIRE PREVENTION BUREAU Inspection date:
48 Lafayette Street Z
Salem,Massachusetts
APPLICATION FOR CERTIFICATE OF COMPLIANCE e
❑ One Family Dwelling .
To: HEAD OF FIRE DEPARTMENT ❑ Iwo Family Dwelling
ndominium Unit N
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 approved installation of smoke detectors.
Type of Detectors: A. Monitored Ba ery Units B. Permanantly 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
Detectors Require Annual Maintainence.
(Signature of Applicant)
Date of Certification:
(Address) �y
By: � V/ —�4��0
���-(Phone)