HomeMy WebLinkAboutBLDCI-23-002944 2023 s .n
,.5-4,� TOWN OF YARMOUTH
i ` BUILDING DEPARTMENT =-,
�� �."w .r% x 1146 Route 28,South Yarmouth, MA 02664 508-398-2231 ex( l�li� C E _IVFD
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APPLICATION FOR CERTIFICATE OF INSPECTION
NOVV 212022
November 1,2022 PAYABLE UPON RECEIPT BUILDING DEPARTMENT
B y:
( ) Fee Rcquir ------
(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: l iJ/55i.v.S CfLi '-U fin.
Name of Premises: /i A/'f/,O c 10,i.s"-, igaik Caw:,/ Tel: ,. 1 77e— 7 z 7 f
Purpose for which permit is used: Z.,ellick#r62 J
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to by kzti"u aP 4. - 1<- Tel: . -at'"- 7 7 Y - 73 7'
Address: refl.) /Yp i j j r 3 CI/1,-.et;A)i/I /' ,-4 ‘A/cj% yio flirt iv i n 4-. tzo'-(7 3
Owner of Record of Building Cis e'. 4)(4>el4,,�, t c,. '4,,!ti rl x...t_
Address 296 .5TA7iv+J /Jur' , ST.,rv-{4. Y r,- f~L.. ,rs�lrq. f..cs-GG `7
Present Holder of Certificate
e<-7Z-------- fj y7 I a
Signature of person to whom Title
Certificate is issued or his agent i/f P-r---
Date
Email Address: T/,"x'c -„.. . ''i_it 1. ,ri;, r,,:%/z-. /1 ,v S
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 CAN OTTj�II,,SSUE YOUR CERTIFICATE OF INSPECTION.
Certificate of Inspection# 5 L2/-,c93_Oba 99 1
12/31/2022-12/31/2023