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TOWN OF YA '"
UT
41
y/,, 1146 Route 28, South a aouth, NIA 02664 508-39 -2231 e x t, 1260
tom.:
RECEIVED
APPLICATION FOR CERTIFICATE OF INSPECTION I
�..._ -�
APR 11. 2023
April 1, 2023 PAYABLE UPON RECEIPT
(X) Fee R Q�1 ��.f��PARTMENT
( ) No Fe
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: ' i I /tl j j ins" G(o w /1 Rye
atL\i/37-', f
Name of Premises: I V V" id:514 v)t ,( eis'r CA ar6�,_ Tel: �� 7 3d i�
Purpose for which permit is used: WC/Ap Sc'ef ic4f
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to JV l spmtrt 1310 t C/Kr&/t_ Tel: 5ai'-'7"I-3d-2-‘'
Address: Lt rj tti,ff ( 4A41 1 o-t'C
Owner of Record of Building S4„,c, .r 44 7),e-
Address
Present Holder of Certificate /1
� ' (Gll �a TLC
460,91 w rn,e$1 7- floe Milo rCr l
ignature oVperson to whom
Certificate is issued or his agent Title 7 7 _ 3(-9 D
Date S �4 i 1
Email Address: h41/ 77 7 7 nasi �. G o eh 0e G9 Lv
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# /- 3, v ZIfti 1
05/01/2023-05/01/2024