HomeMy WebLinkAboutBldg Exp 76 120 Route 6A°�Y� TOWN OF YARMOUTH
�$ 3r0
°,} $ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451 [hE
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Telephone (508) 398-2231 Ext. 1292 --Fax (508) 398-0836VED
OLD KING'S HIGHWAY HISTORIC DISTRICT CONI J ITTEE `.3 2021
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.
Tvoe or print leoibly:
Address of proposed work: /20 ��cJ Map/Lot # Z/
/ ? S-
0 s): d4 4AjG`-( L2>e eA Phone #: 5&$ ^,6 7 /9(,)-3
All applications must be submitted=Ove'c
ner or accompanied by letter from owner approving submittal of application.
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Mailing address: &' � ta
/V'9 Year built: � oS 7
c -A 2 "1206'7 @ q cam.
Email: � l �.1 �41 4 & . referred notification method: Phone Email
Acient/Contractor: CJLI ✓c 2 /<a
Q L� Phonee #: �8- So . 76y-0
Mailing Address: O u�/� a Q / &,) �r"�J/�, �/j2� f" 4 0,26 /�
Email: eEtt 1& %!v G a) CGS-OJ:� 62/referred notification method:
Phone -Email
Description of Proposed Work (Additional pages may be attached if necessary):
Signed (Owner or agent):0Q,Date: l 2 `-S - 2z
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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:
Amount
Cash/CK #:
Rcvd by:
Date Signed:
vs.2ov
Approved
Reason for denial:
Signed:
Approved with changes Denied
APPLICATION #:
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