HomeMy WebLinkAboutBCOI-23-1812 2026 4Y4 . TOWN OF YARMOUTH
,� -- =- Office of the Building Commissioner
y, 1146 Route 28, South Yarmouth, MA 02664
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' 508-398-2231 ext. 1260 Fax 508-398-0836
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" '"� APPLICATION FOR CERTIFICATE OF INSPECTION
November 1, 2025 PAYABLE UPON RECEIPT
( ) Fee Required$100.00
( 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: 210 5 1-0 no() Ave-
Name of Premises: Der)r( s 1 amu i-in I2e I Uf(t I Tel: Q' -39.g- I o3O
, 1100(
Purpose for which permit is used: L J i O n -
License(s)or Permit(s)required for the premises by other governmental agencies:
License or Permit Agency
Certificate to be issued to D .i 42.5 l) Tel: 9 g-39g•r((p 7 7
Address: 2C1(p 5-Q.-i 0n ,/- l7l yv f h \l(,t vryl rU{k
Owner of Record of Building
Address
Pr- Holder of Certificate N p 6 b
ibi es
Sig ere o perso Tale
Certificate is issued or his agent 1 t `i 12.5
Date _
Email Address: i.ve'1e✓6 C I A -lili
o n6.\ -►L t 2-rr t}5 _,
NOV 17 2025
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# BCOI-23-1812
12/31/2025-12/31/2026