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BUILDING DEPARTMENT
, .A.,,t, \t% TOWN OF YARMOUTH
(,:,�MA yF5/=,'9'' 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
�'Wakratin,f �.:`� T '
APPLICATION FOR CERTIFICATE OF INSPECTION
June 1, 2023 PAYABLE UPON RECEIPT
(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: {d2 n 4tO1nkt, (04 j 1�/cA rreloa'Lark't tO $7 5- (ift,Z 3 Li �)' r0
-- � `
Name of Premises: c fv t pp'I t,me 6Crr e 1 Tel: O%--4,44 4100
Purpose for which permit is used: 6-1 t Uc c . csv,1Q ec,.c %t +u.1,wr cGf11"4_✓
License(s)or Permit(s)required for the premises by other governmental genies:
License or Permit Agency
Cl Ogg 0(o"1 \i -_o� ( L-'4ucf%\'kor. uri8 Colt„
Certificate to be issued to Tel: O3 5,.2.—141cX3
Address: 61
Owner of Record of Building t n1
Address 1 )' r t r s 1'
Present Holder of Certificate M cl
Signature on w om Title '�`�_—
Certificate is issued or his agent ( SD A, m--.r._- -
Date pa JUN 3 0 2023
Email Address: i ,gyp
BY
Instructions: Make check payable to: Town of Yarmouth
r - - 1---j
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# f7/-o?3/72.j
07/01/2023-07/01/2024 /