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AT L ` . 1 V_.ED. 1146 -Route 28, South Yarmouth, MA
�► 02664 508-398-2231 et. 126()
MAR 21 2023
PLICATION FOR CERTIFICATE OF INSPECTION
BUILDING DEPARTMENT
M PAYABLE UPON RECEIPT
(X) Fee Required$172.00
( ) 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: I4
Name of Premises: t, 7 , . 1
W l S C\ 1 (� S �+ � Tel: '79,(1 1 0�
Purpose for which permit is used: d �c-.LQ ,e, U S
License(s) or Permit(s)required for th premises byv other governmental agent es:
License or Permit Agency
Certificate to be issued to EDn,`cty, 03rec
A,„.krnn- nn.A Te1:-1-6FS'-p go-Ta9C?9
Address: a-ti?it 77 , r-
Owner of Record of Buildin '�� � �
� j
Address g r
Present Holder of Certificate 5 �
Signs re of erson to whom Title
Certificate is issued or his agent
Date
Email Address: V\Spe C
14 445;e_ cgrt CM c'f / sue-
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 ISSUEYOUR CERTIFICATE OF INSPECTION.
"Certificate of Inspection# ,
04/29/2023-04/29/2024Z3—�dS� rt� —� p C