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�MATFA !1 t�.a)'CC 1146 Route 28, South 'Vat-mouth, MA 02664 0 -39 -22 1 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: 9 L, ( S T,\T )t`
Name of Premises: Sw&El lb 11-4-12k7 O C S Tel: 5c-='`6 to a ray
'�
Purpose for which permit is used: 9 -t u' IAi( 1
License(s) or Permit(s) required for the premises by other governmental agencies:License or Permit Agency 1°‘
\\ 414
Certificate to be issued to )W E ( 1`.-k ickZbcS Tel: Sod 2 605L
Address: -\ r Ai Z_d r-i r3rU 5 r 1� A 01.._
Owner of Record of Building 'w\''( LD? RECEIVED
Address \S C Vw+i S< , `` .\\ "8/8,8Pe-
Present Holder of Certificate
NOV 2 9 2023
\\J\ k -�-- .� � ,oZ)
B LD APARTMENT
Signature of person to whom By: _---
Title
Certificate is issued or his agent
Date
Email Address: b SW•F -�� -V\nd. . (' " 1
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 he 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# 6C-a-d,3— .3
12/31/2023-12/31/2024