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1.1r4mt TOWN OF YARMOUTH RECEIVED
BUILDING DEPARTMENT
O . H
1146 Route 28, South Yarmouth, MA 02664 508-398-22 1 xtJl !l116®8 2024
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BUILDING DEPARTMI'NT
APPLICATION FOR CERTIFICATE OF INSPECTION sy.--
January 1, 2024 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: 3t 0 12OW4L ( Pt ,ya irrir—7--y) PO(+ ()2.(0` 75
Name of Premises:/O,rYYl(1k'tY1 Fire- Sta-*1 . Tel: MO' E.'22t2-
Purpose for which permit is used:
License(s)or Permit(s)required for the premises by other governmental agencies: /4
License or Permit Agency
Certificate to be issued to C;hiec End u_e__ rrOSW-e, Tel: , - C2_
Address: 340 is A, "l C.l rf-n l Pr - m A 02-VI
Owner of Record of Building --Rxor
Address f Ql4 c3 Lk 2$3) S•ycLi-r n Inn Pc- C5ZI,.cC-t4
Present Holder of Certificate •larcn0LX-A1^m l Dept-,
AdirYitn, Assi Sf-c1t1-1-
of person to whom Title
Ce .to is issued or his agent 0 1 O FZ07--L4
Date
Email Address: i Y-CCn.e o `'
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#
02/13/2024-02/13/2025