21-E067 t 41..x_4*.,„c
TOWN OF YARMOUTHfs. { RE
��' x 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4451
Telephone (508) 398-2231 Ext. 1292—Fax(A50082)63691.4(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: ' 1
�? '1 W '(34-V...�..LC.1 t-�, p � f Zs
Address of proposed work: `,ri Ma /Lot# �
Owners): 7Drt\-(1s 1Kji1-"cE..\Jk Phone#: (10-LlI( '1 'j-7Ok
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: Ck bk W Pct. O ct. 5 ), kgtfirk 114 Year built:
Email .k\r\vko1/4,,Nki;, ;' Jl. ak.4\ _C ' U.:Ln Preferred notification method: Phone (/ Email
Agent/Contractor: _�'}fit.- .CT l...- \j TJz A j Phone#: 0, 711 )L2_ 7,J(9.t.j
Mailing Address: ',' A-'er i0.-› ,Vilia1?li
Email: Preferred notification method: Phone Email
Description of Proposed Work(Additional pages may be attached if necessary):
\— — VO i\- -- -C �-- p 'C cct. 'Itfes- -W Ak-tc),24D'R. ..
RECEIVED-1
JUL 2 3 2021
OLD K NG S HIGHWAY l
Signed(Owner or agent): Date: 7 ' L('( 2_1
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: (a Approved Approved with changes Denied &
Amount '2 !) .1 Reason for denial: APPR V i
Cash/CK
//#:� ' V JUL 2 8 2021
Rcvd b (.9" --
y YAi=iMOUTt-:
OLD KING'S 1-ii3H YPY__
Date Signed: Signed: (
APPLICATION#Q \ ...t) `
V5.2017
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