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6TOWN OF YARM FR----------'----ECEIvEDOUTH
1OOARMUA SAN
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Ot n KINRMOUTH
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTTt Hi HwAy
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.
Type or print legibly: p / )4414,4 41/441
,/ �/Address of proposed work: 9! `f� W /'� YQMned/�'j Map/Lot# /a . a6
Owner(s): C'(� Pie L � i Phone#: r/5 3a0 PVc2
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address 44`7 ACJ A,.)e,1J it.,f- i.-‘44,-/-- ivy ps,weN..)j7)fr Year built: , ,;',5 :.)
Email: Preferred notification method: Phone Email
Agent/Contractor: h jQjd,/ ? Phone#: 178 '',0 64/f
Mailing Address: /5- , At f`^'K 1 rdy/ki 4/, 1W4
Email:tie 7h (Ail✓4/40 CDHSirut-,4\I o h.t4,LCo hyt Preferred notification method: Phone y Email
Description of Proposed Work(Additional pages may be attached if necessary):
RECEIVED
0-P y �ws
1 JAN 2 8 2020
TOWN CLERK
SOUTH YARMOUTH, MA
Signed(Owner or agent): afa Date: //at/80
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 am�
1, 1 _4/ Approved Approved with changes Denied
Amount ?� Reason for denial: APPROVED
Cash/CK#: 1 3 q a ° JAN 2 7 2UZU
Rcvd by: AV YARMOUTH
OLD KING'S HIGH V.'AY
Date Signed: / 2 7 202 0 Signed: `J t" �to���� �„
l64: APPLICATION#: �( FC,C76
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