HomeMy WebLinkAbout20-E007"o TOWN OF YARMOUTH
t �x 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451il�
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OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTlLE -'111' 2020
R ��,vJEDOI U �AHUTH
APPLICATION FOR
JAN ;� �� CERTIFICATE OF EXEMPTION
Ap IAV40fRdo
b8 ppnade for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 470 of
Acts of for the proposed work as described below and on plans, drawings, or photographs
accompanying this application.
Type or print legibly: /� {
Address of proposed work: LO n y,jk1� r -y �W(04 100 A— U Map/Lot # 1 5
owner(s): C Vy-j-1�c - - IV "I c-Cc
a:'� �3
�►y Phone #: (, iI - C%, - i - 2 3
All applications must be submitted by owner or accompanied by . tter from owner approving submittal of application.
Mailing address: �� �v► W �w!(. �i (vY•c ,��� �j Cr��'f� Year built:
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Email: C✓"� Lct r � 11 �3 , ' v"',c i , C" Preferred notification method: . ,r( Phone Email
Agent/Contractor: i_ I xC
Phone #: 1717 � -S-G.3 -- (-' A) -c
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Mailing Address: t t: zG 31
Email:�G �]�1i�tlirrc (U(�ur. [ ,".�c �'� ttr'►� ►�-& eferred notification method: X Phone Email
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Description of Proposed Work Additional pages may be attached if necessary):
C. (cal �t1�C �'� �C•LCn c+�� U ����4fi C�.�c.r ii�CfM(s;.zC.Cv,c��r
C(I i�
ti�1e�� C.LAglc �X V\.V17 :-�v'%J C�w. a►n �fU✓�f �oc
Signed (Owner or agent):
Date: t—'o I — ;-y'2U
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 oniy:
Date:
Amount ; X[)
Cash/CK #:._j_j %(
Rcvd by: 4�/-
► Approved Approved with changes
Rpacnn fnr dpnial-
Denied
Date Signed: ! Zo -2,b Signed: 6/� �� J
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APPLICATION #: 4-3�Ipa 7
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