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TOWN OF YARMOUTH
;0, BUILDING DEPARTMEN " RECEIVED
1146 Route 28, South Yarmouth, Al 02664 508-398-2 31 ext. 1260
� � � OCT 11/2013
APPLICATION FOR CERTIFICATE OF INSPECTION BUILDING DEPARTMENT
By -
October 1,2023 PAYABLE UPON RECEIPT
( ) Fee Required
(X) 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: 31 Dupont Avenue
Flax Pond Recreation Area-Lorusso Lodge
Name of Premises: Town of Yarmouth - Recreation Department Tel:(508) 398-2231 x-1520
fAN\
Purpose for which permit is used: Assembly Space \\\:,j
License(s) or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Entertainment License/Weekends Comm of Mass
Entertainment License/Weekdays Town of Yarmouth
Camp License-Summer 2023 Town of Yarmouth
c
Certificate to be issued to Town of Yarmouth Recreation Dept. Tel: (508)398-2231 x-1520 `v�\
Address:
424 Route 28, West Yarmouth, Massachusetts 02673
Owner of Record of Building Town of Yarmouth
Address 1146 Route 28, South Yarmouth, Massachusetts 02664
Present Holder of Certificate Town of Yarmouth Recreation Department
Anthony Bennett Recreation Director
Signature of person to whom Title
Certificate is issued or his agent October 14, 2023
Date
Email Address: recreation@yarmouth.ma.us
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# i3 L,O/c 3__/772,
11/23/2023-11/23/2024