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\ TOWN OF ' R NIO LIT.
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BUJ.ID Via,PA RTMN -
} ;," 1146 Route 28, South. Yarmouth., MA 02664 508-391 -.2211 A74,c c E & V E D
APPLICATION FOR CERTIFICATE OF INS MAR 16 2023
.
March 1, 2023 BU1LD1c � �K rn ";�T
PECTION
PAYABLE UPON RECEIPT By
(X) Fee Required $205.00
( ) 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: Y1 fi,(1 j `IA S t f
Premises: it3 tc, c,; . 2)' ' '
Name of.
ue. c��_ . €a.ek Tel: 54Fa 17.;'1`3 C,g(a')-
Purpose for which permit is used:
License(s) or Pennit(s)required for the premises by other govenimental agencies: -�
License or Permit
Agency
Certificate to be issued to y,e `� 1"�5c fib" Tel:
Address: '3 1 7 CL, 5, y.-,,o-�1 Al
Owner of.Record Buildin T6`f
( r� e�?si!
odd
Address �__ -_ re S,-
Present Holder of Certificate (i"L. CO c-4 rya d e
mature of person to whom
'Certificate is issued or his agent T
1_ 1
1: Date
Email Address: ( C%, ,.c c 'I� �%nrac :4_,Ltr
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 ford) with accompanying f
ee must be building or or part
thereof to be certified. Application must be received before the certificatetted fwill bor eace issued' The butilding official shal
be notified within ten(10)days of any change in the above information. 1
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH TH
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. IS
Certificate of Inspection# 3[062. -/6 —ea J6 a
04/0.1/2023-04/01/2024