HomeMy WebLinkAboutbldci-16-003283-05 (3) �k.-y, TOWN OF YARMOUTH
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� BUILDING DEPARTMENT
� 3n 1146. Route 28, South Yarmouth, MA 02664 :iff$-39$-Z11 Eb1 'y v E D
APPLICATION FOR CERTIFICATE OF INSPECTION OCT 12 2021
October 1, 2021 PAYABLE 48 AC'aFA TMENT
(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: �/th // °IV ST
Name of Premises: c//�w1 ixa, 's �, -&t yi /; i S � / 7 O???
Purpose for which permit is used: 1 7/ 24-N`7
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit Agency
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Certificate to b viss ed to / i/4 '0//vQ j — iL iC "'Tel: S2f /7 elJ'3J
Address: p 7 /9 /N .57'- 7. -%/9/ Olft`7,%%, di 2C Z f
Owner of Record of Building .S/f-yY
Address
Present Holder of Certificate //tip ' / ,4-,7--
P/24"-"J!/eN 7-
Signature of person to whom )2 •
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Certificate is issued or his agent
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Date
Email Address: rd Q -IL cf i 3&c0/¢4 , Go Ai
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# £aid-/6,--O 3 -pS
12/31/21-12/31/2022
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