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COMMONWEALTH OF MAS SACHUSETTS BUILDING D E PT.
TOWN OF BARNSTABLE
APPLICATION FOR CERTIFICATE OF INSPECTION JUL.-0 2 2021
Date
TOWN OF BARNSTABLE
x u N� � � ( } Pea Required$ S_ 0.00
O 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: 276 (-0MK U lC&
Name of Premises: 'tHiQ — 2 K CVD AMD "ES-LAIVO S -,s jr POZU-Ig/
Purpose for which premises is used:
Licenses)or Permmit(s)required for the premises by other governmental agencies: SCOED
Lmcense or Permit 0u GR`Q4,V F '1 5CC4 0CAY AD=
Certificate to be Issued to: 7'ILf_rh(���f�t� i' ` (*j �LSt�U� � ��►1�a,
Address: ' CA M M U MI C �tt t! &A-S/ 4V kiJdU I S AI A-- a 2 y
Telephone: 0 7 C'' — '
Owner of Record of Building:
Address:
Name of Present Holder of Certificate: • �H t i. EIS 4
Name of Agent,if any.
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PLEASE PROVIDE EMAIL: 'v/iy ;)
SIGNATURE OF PERSON TO WHOM CERTIFICATE
IS ISSUED OR AUTHORIZED AGENT a certlfieate to you.
NA ( ��- �
PLEASE PRINT NAME
I NSTRU(MONS:
1)Make check payable to: TOWN OF BARNSTABLE
2)Return this application with your check to: BUILDING COMMISSIONER,200 MAIN STREET,HYANNIS,MA 02601
PLEASE NOTE;
1)Application form with accompanying fee must be submitted for each building or structure or part thereof to be certified,
2)Application and fed must be received before the certificate will be issued.
3)The building official shall be notified within ten(10)days of any change in the above information.
FOR OFFICE USE ONLY:
CBRTIFICATE#
EXPIRATION DATE: ���
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