20-E011TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext. 1292—Fax (508) 398-0836
RECE
OL KING'S HIGHWAY HISTORIC DISTRICT COMMI
FEB '13 2020
APPLICATION FOR
Hi_no�11je,i,
0101 1 1 83J
TOWN CLERK CERTIFICATE OF EXEMPTION
SOUTH YARMOUTH, M
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: ll,�' t G�C1H �� � p[� 1 }1 5 .'� MaplLot# ,,�Z -4�
Owner(s): �-l ' (_ Phone #:����
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: L4V RC_" 5r-. i(�� C► �t� [�{ �C-JSY_ear built:
Email: th � 1 C c.0 r�Ci ��y}t,c ,�� LQrr, Preferred notification method: Phone Email
AgentlContractor: Phone
Mailing Address: l
Email: r�CZ �rn#�r�c�notification method
Description of Proposed Work (Additional pagesmay be attached if necessary):
✓ Phone `J Email
Signed (Owner or agent): V/�_ilc•t �� Date:
Ownerlcontractorlagent 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:
Amounty
Cash/CK #.
Rcvd by: _
V Approved Approved with changes Denied
Reason for denial:
FEB 13 2020
YARMOUTH
Date Signed: --03z°2c� Signed: APPLICATION #:
V5 2017
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