18-E132 i
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TOWN OF YARMOUTH
er1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
•�
V, :~ Telephone (508) 398-2231 Ext. 1292-Fax (508) 398-0836
RECEi L KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
UEC 1 12018
APPLICATION FOR
TOWN CLERK CERTIFICATE OF EXEMPTION
SOUTH YARMOUTH, MA
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly:Address of proposed work: \9 Pi hea,sa'It CoVe C t IC (e, Map/Lot# ` H 1 /f7 0
Owner s): Trt L K 4 ACLU Y t-e Y ( e1/4/10 e Phone#: 617-33 / - 7 3c 7
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: b4.) ( &'dar ��'' ' t',4 51 2110/, / nil a.,2 /32''ear built: l /cg
Email: AO /Preferred notification method: 4V/ Phone A0/- Email
Agent/Contractor:.S( 00l/(r'J S-f' t h.1 G-1)Lhl f1, AL//fl' R ti fi Phone#: J-oe- v30- cQ/ c 8
Mailing Address:
Cs U6)( /36Y 77x►' 'C 61 Y,NM 6c 26 c >°i 5--v 'Z & a 9 5�
Email: Nl b/u+e @ coM b t. (1 + Preferred notification method: ✓ Phone ( 7 Email.)
Description of Proposed Work(Additional pages may be attached if necessary):
1 _., p l/Jl f'1 ld Lc) L'-)/
Pi kcLl'� ,exts i).�,� / /C.'�-
G„ /7 to i.d
C k.,e i�t�F c l' II k c L/ 7-
d00 66(
Signed (Owner or agent): ,:- • /-=;t /°/26)40 -
r-- Date:
Owner/contractor/agent is aware that a permit may be required from the Building Department. (Check other departments,also.)
This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:p
Date: J '?-/O—/0 v Approved Approved with changes . ti .-' Denied
Amount
&C), Reason for denial: "i"� 4w'4...',L,
Cash/CK#: .99 `4 , DE 1. 1 9 ' ,
Rcvd by: . OLD KING vwu fH
�— s HI.;HWA,
L 6
/ 20 - �" C
Date Signed:/ / / / Signed: ,� if' "-� APPLICATION#: 18 /3
cq
V5.2017
6
g °�Y TOWN OF YARMOUTH
Mi° "� I� 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
�,Mi4>ru:�� 5 ti
Telephone (508) 398-2231 Ext. 1292—Fax (508) 398-0836
RECEIVED
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
DEC 1 1 2018
TOWN CLERK APPLICATION FOR
SOUTH YARMOUTH, MA CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly: ./
Address of proposed work: \ Ph egoa r1� Ct tf e L. I r c, Map/Lot# I t", 1 A 0
Owner(s): Ta(..K r Pao{c (\ 1 -t;k1 In e Phone#: 6 17- 9,3c?
3� i -
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 50 eerVC(h Ve ^ West t611:),.7 ! 11p9 t),2 /,32Year built: / /9 c2
Email: ./1.01 Preferred notification method: jv/A Phone /0-. Email
Agent/Contractor: S-G{i,c'a/l(o US-t' t J n3 G)oil .Xie- /) t !fl 7R/4.4-e Phone#: .6-0e Y30 - c2/(7 8
t.
Mailing Address: P 6 LJi1( /,36 l ruiic '1� 47/ 6-26x° /� c ?!� ;5� `f6 .� / � 9
(,�ki
Email: kIVI b/u C COM oaf. It 11 Preferred notification method: ✓ Phone {/ Email
Description of Proposed Work (Additional pages may be attached if necessary): J
PI �c�44 €Xrs -i,
//7 �0 �
Si ned(Owner or agent):
le______- /vy �� w/��)/�
9 ,�-(�� Date:
> Owner/contractor/agent is aware that a permit may be required from the Building Department. (Check other departments,also.)
> This certificate is good for one year from approval date or upon date of expiration of Building Permit,whichever date shall be later.
For Committee use only:
/g-10--1 g' V Approved Approved with changes --_ Denied
Date: ,' �'�_
4ti y Ir:.;�kVlig r,
Amount �D Reason for denial: �, � � .^•-
1.3e tli_
Cash/CK#: 7/ e"l 1 L 1 i 0 ,g..
Rcvd by: ?'lt,,n,OLDU I
G
S
' -NI�aH
NWA.
•
"Date Signed:////e/2-0/5- Signed: J( E f - -•-
APPLICATION#: lF-"E/`3ca
v52017
4.
. clay_ .;:).. 0._
K I-4
SECTION 5: CONSTRUCTION SERVICES V
5.1 Construction Supervisor License(CSL) �?S -0'� 7l;;1 ,3i, f a:Jl
9
Ke\‘n 0 'P' 1,-k License Number Expiration Date
Name of CSL Holder LA
q List CSL Type(see below)
No.and Street Type I Description
I�" r t. , 111 O r+ U I Unrestricted(Buildings up to 35,000 cu.ft.)
'VS 1 I `f R I Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS I Window and Siding
` r`' 56 , .,1 a k 4��� t?C�Y� •�+n�r SF Solid Fuel Burning Appliances
J1 V l5 U lY�'1 I I Insulation
Telephone Email address 1 D Demolition
5.2 Registered Home Improvement Contractor(HIC 0 b
S lt* \�u cp... Conova-uo UAL- i(-evl✓t ,3i lug I R I rf y `f (��( ra 2 2
�, o% HCC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
CI -Ld k w•X'j VP)Ij\wl2CCOMCCIST: nefi
Not.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit. /
Signed Affidavit Attached? Yes l' No 0
/
. 4 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN /'-
OWNER'S AGENT OR CONTRACTORfAPPLIESfFOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Ci! f t l l.I"Sa' C ) ,��G
to act on my behalf,in all matters relative to work authoriz•. .y this b ilding permit application.
,`
• .1-e 4' / AO" - 1L elk i It 1 I2- 2-0(b
Print Owner's Name(Electronic Signature) C&------;....01.,,-t,.;,,—.."2.---
to
revel. 7...11 ✓ `2.---
• SECTION 7b:OWNE''OR AUTHO' ZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.trov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling.system Enclosed Open
3. "Total Project Square Footage"maaSagtdted foi otal Project Cost"
0 c , ' 2018
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