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TOWN OF YARMOUTH
„ . „ .$ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
::.rte 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: I a G'Ltn Lia Le 14.) (./ CcR �-�-
dla ofi PP0,11± Map/Lot# 39 14
Owner(s): KAnn,c.-{.(n + k0 (l Pct JW( 2 i4- Phone#: L((3 ' Se. 3 to t S -7
All applications must be submitted-by owner or accompanied by letter from owner approving submittal of application.
Mailing address: l 2 & i/N w•• CI- Wc.v( fGLi-/14.63-ac 1, Pact D a6.73 Year built: I i 7 3
Email: ec v 4-1? 0.z- CapAcc j 1• .n c-t_, Preferred notification method: Phone Email
Agent/Contractor: p (PIrN
J l S 0 N ttDM� c 6 Ll t 'd i lis L-•LG Phone#: 1 " 774 - ?-36r^ O Y 3 4'
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Mailing Address: t' o 20x... (0 3 CO e S'r BOA NS'L L Le. 0 D:764.0
Email: j
p h u✓s ca h c rx .6u 1 lAs r✓q eA1-6'flu., (Preferred notification method: Phone Email
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Description of Proposed Work(Additional pages may be attached if necessary):
N l �%)(ls4-i L/ DLCK 1 (16W A
pd4,,,/ -GRECD EI
i
AUG 1 $ 2021
YARMOU1 ri
OLD KING'S HIGHWAY
p ,
Signed(Owner or agent): Uk,4JL Date: a
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:$/)ttG/ act 1 Approved Approved with changes C Denied
Amount//////'2.0 .00 Reason for denial: APPROVED
Cash/CK#: KIt4) AUG 2 3 2021
Rcvd by:V'\G..
YARMOUTH
_SLD KING'S HIGHWAY
2Q t4
Date Signed2J 2� Signed: 01 - v
APPLICATION#:
V5 2017