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TOWN OF YARIVIOUTH
/* ''\'4?:%
ti" MAT � x BUILDING DEPARTMENT' ; °° @.LZ,- =`' 8, South Yarmouth, MA 02664 508-398-2231 ext. 126(1 L R E C E
n 9 J U N e12021TcO FOR CERTIFICATE OF INSPECTION
June 9, 2022 BtialNG DEPARTMENT PAYABLE UPON RECEIPT
(X) Fee Required 118.00
( )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: /.i'76 g c,d/e Sf , (IC) �.�.�.�c t>7 J , ,�} Z 6 .y
ti
Name of Premises: 8.4 ,s /eve"? ca-4,1 , ,, /.,.,.717o,,• Tel: o'er, y99 Jc
ail
Purpose for which permit is used:
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
6,455 R.Jt - Zjciri fry.-,� %d✓e7AO ISC - /OU.Sf
Certificate to be issued to i n se e c It csr Tel: ,j 08 --,-3 p s 9("9?
Address:kor,tif can - itibrve.
wner of Record of Building '' Co-,c/c,,,;., , , C-,-,-,p/-ex /8 v:-,.'ts - /e 5-44'j vet 5
Address i-t1 1/ C-e .,4- eeic. /: /. 0 . 8ox ♦6 82., E",J‹n.)Is, ,4 c.1 2.co <//
Present Holder of Certificate 5 s s e•%e,L 34 & -Town
tior'sc S
S gn re of person to whom Titl J
Certificate is issued or his agent 6 _ 2 7-20 2 Z
Date
Email Address: en //e- ed c..i . Cv.
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#
6/1//2022-6/30/2027