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REQ
1146`Route 28,South Yarmouth,MA 02664 S08-3' I.2 t ex 1260 -
ED
APPLICATION FOR CERTIFICATE OF INSPECTION
MAR 292023 -
March 1,202 PAYABLEUPON REC , j;_ (X)FeeRequired j l'LDi . ),1� � J
( )No Fee Requtr $y VI7
In accordance with the provisions of the Massachusetts State Budding Code,Section 110.7, I herebyapply for a
Certificate of Inspection for the below-named premises located at the following address:
Street and Number 9 .: " cc .. gitet,e€ AL-ye.
Dame of` re '. altZig „Ad"?t",eflo;ipi,:fie7 Tel. far'7. 1"4:kbl--4: 3 ff
Purpose for which wit is used;
License(s)or Permit(s)requiord for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to ee;' ' - /ik5 I, t Tel: 9 ' -e `- 043
Address: fa' . + hi �i� *t - t < � yam
Owner of Record of Building f 4 & "'/Sr'S `
Address ! artzeoste Wa , 11?i r 1 f, e ,
Present Holder of Certificate
at
Signature of et whom Title
Certificate ia Issord ►r his agent 3 !`C
Da
Instructions: Make check payable to: ' Town ofYarmouth
1146 Route 28, South Yarmouth, MA 02664
Return this application to.' BuildingInspector'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 CA1V OT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection#' ,/—, jti(, -37/.,
04/15/2023—04/15/2024
1di #