HomeMy WebLinkAboutApplication for Certiciate F ° :Volk TOWN OF YARMOUTH
o � - BUILDING DEPARTMENT
1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1260
APPLICATION FOR CERTIFICATE OF INSPECTION
July 2,2019 PAYABLE UPON RECEIPT
(X) Fee Required 150.00
( ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code,Section 110.7,I hereby apply for a
Certificate of Inspection for the below-named premises located at the following address:
Street and Number: 1 (ck I'tn.A 2 weAl ' 01-rtn i . \ M i o2C 7 3
Name of Premises: tM A pl &tie:›00.1) 44 m111 i/f Tel: 7'lee V77 -G/7c
Purpose for which permit is used: t_7ci i 3
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Perm_t RECEIVED Agency
AUG 26 2019
BUILDING DEPARTMENT
BY - -
Certificate to be issued to ,M,, eW -i S)4 It Tel: 77C�t(�'76..- l i�'
Address: 16 tY t�LnJP.J a.,— %oc,41-1 (Vt A 07_4 7 'S
Owner of Record of Building nil 41 f. , J00r) r p r /WW b L
Address One- C-orkdm >�!t o.� �'er-It', Oc r_,✓e#j---- G-1- b t O
•
Present Holder of Certificate 6112/g. L-J m D A(- ivt i jI big(
-kAatkirwvice- EftOrofvywaol e-i-Vic.4 4-1
Signature of person to whom Title
Certificate is issued or his agent
Date
Email Address: V Viltint g le tvGre RI. Gov,/
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
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection#
8/21/2019-8/21/2020