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.,„'i•YAR TOWN OF YARMOUTH
of .yam y BUILDING DEPARTMENT
N' "`.;s". 1146 Route 28,South Yarmouth,MA 02664 508-398-2231 ext.1260
APPLICATION FOR CERTIFICATE OF INSPECTION
September 1,2023 PAYABLE UPON RECEIPT
(X) Fee Required$150.00
( ) 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:
y
Street and Number: I �+ +` A KW, u 1-
Name of Premises: � d i'^ Sott 5 ��-Z NotS .��e §Oe-3qy-3S/q
Purpose for which permit is used: v
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
,;IJ;.,y /(fUrS tj tioittQ
Certificate to be issued to ' (4,40A125 Tel: 509-ok11-/9/3
Address: aG6 .0. IL444.056.4.z4- Soork 1/i4.N4+ iv% O a
Owner of Record of Building .rA:rv;e., rx4_ C.i a Str rc..s .Zi •
Address
Present Holder of Certificate TA t., t'3/5 i4/414 1 Cat
Precie aF L�.a,,+ cry
gnature of person to whom Title
Certificate is issued or his agent /P-5--dot;
Date RECEIVED
Email Address: Ildl161•eJ C"i Z ti-k51•bf3 DEC 05 2023 J
B YHKIMtNI
Instructions: Make check payable to: Town of Yarmouth ar } j
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# 8CCV-Q3/fO-'
10/10/2023-10/10/2024 /halintf /n)eyri-1..S2i Dig