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TOWN OF yy
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DEPARTMENT
114E Route 28, South Yarmouth, MA 02664 08-2 8-22 1 ext. 1260
APPLICATION FOR CERTIFICATE OF INSPECTION
October 17, 2023 PAYABLE UPON RECEIPT
(X) Fee Required 200.00
( ) 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: /06D el, ag' !----
Name of Premises: T C Dc -I LS Tel: 6Df 39Va303 OCT 20 2023
/ IL ICI ,
Purpose for which permit is used: Fas� ,c44,4 1�o5'�trN4„rc71-
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
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Certificate to be issued to int.,1)(krtc�jr)1,5 Tel: ,�8a3O a190
Address: °V7) e)L1.Lie r ,;L1R/' /.0 ly•FAD i-on M S[o
Owner of Record of Building me.Ls! ' f/yi
Address Sa ynr S aloou
Present Holder of Certificate In t wzotis s'
9.e _Ane 1'WO -7 rfrtv -
Signature of person to whom Title
Certificate is issued or his agent /07/02�
Date '/
Email Address: e eel nut'•nee nA,n hrrroni.do 9,1
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 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 CA ,,OT ISSLiE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# �X,L,1- !3_ /7(/ l-ZL11�-�(� 11 ot/
2/24/202-2/24/2024 ! I
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