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1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-445.1
Telephone (508) 398-2231 Ext. 1292-Fax (508) 398-0836
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Mailing Address (cr\L'tt
Email
JAN I 0 2020RECERlvloutOLD KING'S HIG HWAY HISTOR]C DISTRICT COMMITT G,
APPLICATION FOR
CERTIFICATE OF EXEMP TION
JAN 14 2020
TOWI! CLERKsourn ynnuouin. un
Application is hereby made for the issuance of a Certificate of Exemption under Seclions 6 and 7 of Chapter 470 ofActs of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Tvoe or o nt leoiblv:
MaplLarltLl/74
Owner(s)0nh:
All applications st be submitted by owner or accompanied by letter trom owner approving submittal of application.
Mailing address
Email:
Year built
Preferred notification method: _Phone Email
/\Preferred notification method Phone Email
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Descrioti on of ProDosed (Additional oaoes mav be attached if A b^,nr6 1
f|.c goul,
$ln"ft go,J,r
C-or,kA r col - lqon b,,h (n6arc.ho" Q>c["n." t^
Signed (Owner or agent)
oate: l- lo Qb
Amount a
Rcvd by:
,",.,lllol/q
_Approved with changes Denied
Date Signed
rmit rhay be required from lhe Buitding Oepartment. (Check other departments, atso )pproval date or upon date ol expiration of Building permit, whichever date shall be latercenifi
Owne cont nacto 5 reawa th a a
sThi rscale fo e a rorn agoodye
v52011
2?zo Signed
a6
APPLrcArroN #:J o' trr:c''4
o
TOWN OF YARMOUTH
Address of proposed work:[.[\,r I ^,..Z1
pnone *: Eot41 S- l4l7
AoenUContractor:,n*.o,eot -17{-f,411
/ aep,ru.o
Reason tor denial:
For Committee use onlv:
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