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TOWN OF YARMOUT
°tt '�\raYff 5K,_1. A . ..ENT
- " 1146 Route 28, South Yarmouth, NIA 02664 508-398-2231 ext. 1260
474
APPLICATION FOR CERTIFICATE OF INSPECTION
April 1, 2023 PAYABLE UPON RECEIPT
(X) Fee Required$412.00
( ) 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 t
Name of Premises: Sam Pe9 -�- �al,j Tel:
Purpose for which permit is used: Lo
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit
Agency
[RECEIVED
L APR 2 8 2023
Certificate to be issued to BUILDING DEPARTMENT
`. Z �oc7 �ei- Tel:
q 3`(`- ey
Address: ( (q ag Szat
Owner of Record of Building '"`"`` °
Address
Present Holder of Certificate
Signa of person to whom Yy .�
Certificate is issued or his agent Title
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 buildin offi
be notified within ten (10) days of any change in the above information. g cial shall
PLEASE SEND US A COPY OF YOUR WORKER'S COMPENSATION INSURANCE FORM WITH
APPLICATION OR WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION. THIS
Certificate of Inspection#
05/29/2023-05/29/2024 �'"