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° UM INC
- EPA
-e - r . F C E ! V D
Ve , ri. sr 1146 Route 28, South ullYarmouth, I� . '.. --
;% 02664 508-398-2231,.. ext. 1260
JUL 18 2023
APPLICATION FOR CERTIFICATE OF INSPECTION BUILDING DEPARTMENT
Jun 29, 2023 PAYABLE UPON RECEIPT
(X) Fee Required $373.00
( ) 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: 13 &kJ(' -
Name of Premises: ,_( c yo Tel: 5 S 17`75 2
Purpose for which permit is used: 4--4cy
License(s) or Permit(s)required for the premises by other governmental agencies:
CS (Ti\rj
License or Permit Agency
Certificate to be issued - 1
Address: Tel: r 61
73
Owner of Record of Buildin
Addr ss 1 1 Pres nt Holder o Certificate I<
Sig ture f person to whom (14 A A)Q "'
Title a �
Certificate is issued or his agent (2 f (�`_\
Date I ( V"
Email Address: f-20.(4--@ ()Qqu. in c,
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 CANN T ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# LCL)/
05/20/2023-05/20/2024 -�3 v��-3(