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Home My WebLink AboutBCOI-223-1709 •„Y�A�y ,... (--„,„) TOWN OF YARMOUTH (----- /, Office of the Building Commissioner 1146 Route 28, South Yarmouth, MA 02664 �`# 508-398-2231 ext• 1260 Fax 508-398-0836 MATLACHEESE / c...„ i E% • " ''`" APPLICATION FO raF PECTION March 1, 2026 � PAYABLE UPON RECEIPT r 0 4 2026 MAY1 (X) Fee Required$100.00 ( ) No Fee Required BUILDING DEPARTMENT In accordance with the provisions of the Massach BY , Section 110.7, I hereby apply for a Certificate of Inspection for the below-named premises located at the following address: Street and Number: 96,q ,e 4e'�6 - l t (� ( ee y /4 411 ! Name of Premises: 2 wi 0 u`T `�. e u ( J rd�1 /A3Tel: ��7 _?6?----0 Qcc- 7 tp o 3Q5-41 Purpose for which permit is used: 6/Vekiy Su I,,,� W�yc 11 or Permits re uired fopremises byothergovernmental agencies: License(s) O q g License or Permit Agency NOL+0 IA gm.) //e 4 CM. Certificate to be issued to gene ;tmo,G41v Tel: C r7-039-67)04. Address: Ca-7 ,,41-e..4 C1 / /,.t.ov4 1 Pt4el, 0.2 7 Owner of Record of Building ,S',41,-e, Address P ent Holder C i cate S,4-1,44 d2eS, Signature of rson to whom Title Certificate i issued or his agent ' D-�/ 4 . ;, ;, Date Email Address: \ �4 rrt o tm-I A"1(ecJ1ey�CO fro(,,�0 ,, �/ pAoia i -o. K-*' ' 0 /9- 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-23-1709_ 04/19/2026-04/19/2027 Y .., C TOWN OF YARMOUTH 1'61% Office of the BuildingCommissioner tE� 1146 Route 28, South Yarmouth, MA 02664 y`" y(c ,,,,„,, 508-398-2231 ext. 1260 Fax 508-398-0836 ' ct °RPpRASEs �b�a� S - APPLICATION FOR CERTIFICATE OF INSPECTION March 1, 2026 PAYABLE UPON RECEIPT (X) Fee Required$121.00 ( ) 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: 87 0 ice- Name of Premises: ,/l i,o u`f t, �t u lAIJ Tel: ('p — �/-78 O 6 I / 6 co QJ y Purpose for which ermit is used: Week Su kb,1 -t l License(s)or Permit(s)required for the premises y other governmental agencies: 8License or Permit Agency 90t-i--(71-Bfry /) 1 Certificate to be issued to �� 1 �o%a;4/. Tel: a t7— 9-.o? Address: V79 Owner of Record of Building c,4 yyt_ Address Pre nt Holder of C ific lose. ,/zeS, ignature of per n t whom Title Certificate is issued or his agent 3/�,15/�� Date Email Address: fiZint7 tall/l Oc a4,727(A) frai e6o1 !1 Ig 7 (1)64( -11 d f -4P 0 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-23-1708 04/19/2026-04/19/2027 The Commonwealth of Massachusetts = 1, Department of Industrial Accidents ==r1� 1 Congress Street,Suite 100 ,`=.''r Boston, MA 02114-2017 —,Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ( I Please Print Legibly Business/Organizati --)._ o Name: �r Oa Crt k ( 1),--‘,„.._L ° C\A- `�.\ (J 5 Address: ( 7 co 7„)--c. ti tY p: '``� t �'� I �Phon#: 6( ' � g-060,4 -ig Ci /State/Zi �(�t , , ��G w I Are you an employer?Chec the appropriate box: Business Type(required): 1.❑ I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.Vi I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c. 152, §1(4),and we have 10.❑Manufacturing no employees. [No workers' comp. insurance required]** 11.0 Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12. ]Other rj( vtno,12. eolfke ih 1-j *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. **if the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#1. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Insurer's Address: City/State/Zip: Policy#or Self-ins.Lic.# Expiration Date: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigatio of the DIA for insurance coverage verification. I do hereb c ify, under a ins an a hies of perjury that the information provided above is true and correct Si ature: Date: OVIL Phone#: i 11_ Pek Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5. Selectmen's Office 6.Other Contact Person: Phone#: www.mass.gov/dia