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h =A- TOWN OF YARMO UTH
ri
-//,..y',yb„ BUILDING DEPARTMENT
\`= - 1146 Route 28, South Yarmouth, MA 02664 508-398-2231 ext. 1260
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: 92.3 ROI, „ (0.A j l eurrr�o l..t os4.` � Oo�?S � ►I�in
Name of Premises: CI,t.s.oe 'C.tob) Tel: ��
Purpose for which permit is used: G1)` c(„,, tc. car+rQ e— .c 5L I.wr
License(s) or Permit(s)required for the premises by other governmental`agencies: C�� t✓
License or Permit
Agency
npe.oc' tlevriii5eivkcipl'iork 0"eg
Cc.rsz.
Certificate to be issued to 6 ur,
Address: Tel: C�pg�*'J(,.2_14 100
Owner of Record of Building 1 6')
al
Address
Present Holder of Certificate i,,, Fl
Signature of i o w om td___
Certificate is issued or his agent Title JUN 3 0 2023
Date b U MEN T
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Email Address: -
h e GlA nc 10W4ar0,n G614a. . Go m
Instructions: Make check payable to: Town of Yarmouth
Return this application to: 1146 Route 28, South Yarmouth, MA 02664
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# dC(j/--a 3/^73/
07/01/2023-07/01/2024