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> ir4'4' TOWN OF YARMOUTH
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;tet - 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone(508)398-2231 Ext. 1292-Fax(508)398-0836
OLD KING'S HIGHWAY HISTORIC DISTRICT COMMITTEE
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:
Address of proposed work: 2 ,3 N i ckc I aS De o e Map/Lot# 1 21 i-121.
Owner(s): The(3 krt. RI on f 6 Phone#:31c 3457-t 9 'fr7
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 2.3 V y t. )(s( D/". Year built: gS l Y
Email: ' l o dote k i' eA(( yaloO, C cotd cotFrivelEWEEknOhod: Phone ler---Email
Abent ntraccol: -roc- POWGt.rlC 0 APR - 5 2021 1 Phone#: , — S'3 2 - kg 73
Mailing Address: YARMO0I hi
LOLL ,• M(' S HIGH JAY n
Email; Preferred notification method: 1 I Phone _Email
Description of Proposed Work(Additional pages may be attached if necessary):
G.ctrretrTt-LI we. due c S Greer .l ;n f alio LA 1% can u as rood'. We_
are re ru the CawuaCOOPS � aid screens. lee et4ccr�C X1`4',
Wt C1' o 4 -rack oe u0,04 si-,uc 2& c 'd uocr4 v'tv, f ood`4s) w d 14.e-
9 mit cxs ei lf- sh,►v) -le z w.. t-
1, i .oQ OA t o ws G, S lie Cs - I e. s CA 4
torca-d- YJj lb Pe. I-, Avpra I(. 29) 5/* '
frF.
Signed(Owner or agent): Cj.J2tJ4.4-c .(/ t,w Date: l,(4:1 I, 2021
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 shaft be later.
For Committee use only:
Date: ,,I Approved Approved with changes Denied
Amount ''7 r 00 Reason for denial:
Cash/CK#:
Rcvd by:
Date Signed: Signed: APPLICATION#:
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