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1146 Route 28, South Yarmouth, MA� 02664 5(}8- 98-221 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
September 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: j / 0 S reo Jte s'
Name of Premises: Pi Ce-GCk. t D f Cf f Tel: 5-QS 39 4.6
�''` ICE E: VED
Purpose for which permit is used: I'n(--)Ca, vi Q' Q )e ( C
License(s) or Permit(s)required for the premises by other governmental agencies:
OCT 15 2023
License or Permit Agency
BUIL.DING DEPARTMENT
ay
J(f� 1 r�e Ca M c }r� S
�on + .'vo, IE�
c .,.kri G C yC,(► 171)4
Certificate to be issued to CaQ �' �� �� �C Tel: 5 aCS- 7 y-d s 6
Address: I t 05 a ),E6 f rl Gi l�n�\\n \I c 2 g 1,
Owner of Record of Building ('(?,,,
Address l ( (�� G r v
Present Holder of Certificate
Signature of person to whom Title
Certificate is issued or his agent /
Date
Email Address: Cc.rec De , Fads a 1 - Gt)
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 bei'ore 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 CER'_TIFICATE OF INSPECTION.
Certificate of Inspection# --/773
12/31/2023-12/31/2024