HomeMy WebLinkAboutCI App 842-02Date: February 1, 2002
TOWN OF YARMOUTH
BUILDING DEPARTMENT
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 260
APPLICATION FOR CERTIFICATE OF INSPECTION
PAYABLE UPON RECEIPT
( X ) Fee Required $ 50.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 106.5.1, I hereby apply for a
Certificate of Inspection for the below -named premises located at the following address:
Street and Number: 69
Name of Premises: 1 5 �_ N�,JC Ahittv—z— az(�
Purpose for which permit is used: S/!/Ke ,aM Eb7e GOLF Cd t%1e S,/
License(s) or Pennit(s) required for the premises by other governmental agencies:
License or Permit
Certificate to be issued to
Address:
Owner of Record of Building
Address
Present Holder of Certificate
Qa Agency
D
FEB 2 002
Fun 31
3i 13 60
--
Tel:
Signa ure of person t6 whom Title
Certificate is issued or his agent O
Date
Instructions: Make check payable to: Town of Yarmouth
1146 Route 28, South Yarmouth, MA 02664
Return this application to: Building Inspector's Office
Please note: Application form with accompanying fee must be submitted for each building or structure or part
thereof to be certified. Application must be received before the certificate will be issued. The building official shall
be notified within ten (10) days of any change in the above information.
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH
THIS APPLIC.ATIO�NyOR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate #
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