HomeMy WebLinkAbout19-E062b
TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext. 1292 -Fax (508) 398-0836
RECEIV&D KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
t J 1 1 2019 APPLICATION FOR
1'OVVN 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: %� %�Q f / /
Address of proposed work: Zi Ear 1J \ Red IBJy h Map/Lot # ` l S-, ` � Z
Owner(s): Dana and L -e e Ins s ty Phone #: CZ6 ! ) �7— i 7z
All applications must be submitted by owner or accompa ied by letter from owner approving submittal of application.
Mailing address: Year built:
Email: Z. a j�r)S C j('e Preferred notification method: Phone
h�
Agent/Contractor:
Mailing Address:
Email:
Phone #:
i% Email
Preferred notification method: Phone Email
Description of Proposed Work (Additional pages may be attached if necessary)'
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Signed (Owner or agent):
Date: 718 /l 7
➢ 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:
Date: —J, -1 g
Amount 490
Cash/CK #: a?! 6 L4
Rcvd by: 6 V
/Approved
Reason for denial:
Approved with changes
Denied
Date Signed: 7 (0 12, a/ 9 Signed: a
APPLICATION #:
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