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TOWN OF YARMOUTH $ffiFr
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"J :/ \r1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext. 1292-Fax (508) 398-0836
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APPLICATION FOR
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Twe or print leoiblv:
Address of proposed work:Map/Lot # /15,9 ?
Owner(s):law't krnn.\,z-c Phone *, bt2-hq €. to/O
All applications must be submitted by owner or accompanied by letter from owner approving submiftal of application.
Mailing address:9a^r1-1,€-Year built l? 25
Emair: orn; ,Htle o q$.)t ,brn Preferred notification method: Phone Email\r
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Signed (Owner or 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, wtrichever date shall be later
For Committee use onlv:
Date:il/bl?t;
Amount
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Rcvd by:bA/
Date Signed:
_Approved with changes Denied
/i'/ APProved
Reason for denial
NOv 7 2019
YARMOUTH
v5.2017
//olZ Signed APPLT.AI.N *' ,9^Fl8
AqenUContractor: Phone #:
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