HomeMy WebLinkAboutACI 6-8-10TOWN OF YARMOUTH
; 4 BUILDING DEPARTMENT
1 146 Route 28 Yarmouth,
, South M� �. 02664 508-398-2231. ext, 260
APPLICATION FOR CERTIFICATE OF INSPECTION
Date: June 8, 2010.PAYABLE UPON RECEIPT
( ) Fee Required $
( X ) No Fee Required
In accordance with the provisions of the Massachusetts State Building Code, Section 106.5, I hereby apply for a
Certificate of Inspection for the below -named premises located at the following address:
Street and Number: 1146 Route 28
Name of Premises: Yarmouth Town Hall Tel: 508-398-2231
Purpose for which permit is used: Government Use
License(s) or Permit(s) required for the premises by other governmental agencies:
License or Permit
Agency
Certificate to be issued to Town of Yarmouth Tel: 508-398-2231
Address: _ 1146 Route 28 S. Yarmouth, MA 02664
Owner of Record of Buildin Town of Yarmouth
Address 1146 Route 28, S. Yarmouth, MA 02 4
Present Holder of Certificate Town of Yarmouth
Signatu of person to who
Certificate is issued or his agent
Title 1
Date
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 R WE CANNOT ISSUE YOUR CERTIFICATE OF INSPECTION.
Certificate # 77i
Certificate Dates: 07/10/10 — 07/10/11