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TOWN OF YA OUTH
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*A MAT ,t 4 .LDING. .. ..
1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
February 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Required $160.00
( ) 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: f '1 / Rt • . sj'Uit r1-1 y frp PA o 11 7-0 . 101 (,-Z b
S RSV L`'e ma 7
Name of Premises: _D3 A A IV L_L C Tel: 3-6 _3 1 SC.' -2 Li c6"-
Purpose for which permit is used: IV\ v
License(s) or Permit(s)required for the premises by other governmental agencies:
RECEIVED
License or Permit Agency
FEB 2 i 2023
BUILDING UENARTMENT
By
345-1 IZZ I/Z=:R Moi-E� —
Certificate to be issued to k //yl,y.i1q/,A 4-P) .L L C• �, �,„sV
Address: ��/ Q.� . „�� el: � �—�
#2 04 00 /_H ,A �'� 6 Gj �6 Y-- 6 q Lr 177
_co(cG 7){
Owner of Record of Building /11P Ft-C'-'
Address � / R� ,r2 � � �.. iv-CT-LA� rvl- �j�/-�4
o t�?f( y `U'vL)7H. M Fl - �?-Z 6�e 4
Present Holder of Certificate O/ F Lce, /L'(ft 14 G )/-f. i,M 7'7
Signature of person to whom Title
Certificate is issued or his agent _ / 3— -2-3
Date
Email Address:
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#
03/21/2023-03/21/2024