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2 in
M UT
BUILDING
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EN
1146 R Route 28,
South Yarmouth,, MA 02664 508-398-2,3 e t. E)1 V E D
� J
APPLICATION FOR CERTIFICATE OF INSPECTION MAY 6 2023
May 1, 2023 PAYABLE UPON RECEIPT ufLiG DEPARTMENTB
(X) Fee Required $100.00
( ) 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: OS 7 d rflL
c Cadin k W n nlip O2o o
�Name of Premises: , 22epiS( Op&STel: .722 39q-ga .)-�,
Purpose for which permit is used: C UA ( • '\ (W) - + �l�
License(s) or Permit(s)required for the premises by other governmental agencies:
` Q rurn'License or Permit Agency
Certificate to be issued to J�• �f I p3 I�L 1,liW t Tel: 72 5 1.(-- /
Address: o�O S d m4 S+• Sf514-I1q `1' C(/I.IM(cit AJ� - , L`
Owner of Record of Building1 Vi'1 02-l0/u Y
i-• `�►nc{S
Address (54 5 O 1d PThti ii St-• S1+t". CjL4 atfi l ✓hA . L1 In
Present Holder of Certificate S GA/ •4- •ovVlc�5 6 i s c c`Q -CIi�.�.v�
63T-4L-WO-UL -
Signature of person to w om Title
Certificate is issued or his agent 5/ (a- I
J Date
Email Address: , A o, c -e S aka U1 S L( 22 2 . L(S CCU S 1-31 S. 1/RI--
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# 1,-g73_/766-
06/18/2023-06/18/2024
1-1,6D1