HomeMy WebLinkAbout21-E121 12 Sheltered Hollow LaneT� I UVVN Ur TAKIVIUU Ill
yx 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: 12 SYCL TC—P_Z'2S Z,6FZ% Map/Lot #
Phone #:
Owners : ��(jL �/1ln/ - -
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: c'� Z7�2z-/-Oc'-" /LDJ Year built:
Email: .01 Z2/7 Preferred notification method: Phone Email
AaentfContractor: --N�� Phone #:
Mailing Address:
Email: Preferred notification method: Phone Email
Description of Proposed Work (Additional paces may, be attached if necessary):
IP�F'L.ritC� GX/sTixl� Gv#47Z V/A/S'L S'/d�i� j Lel rTf� C 4PC- 0-. )
>� U14) YZ-
7
Signed (Owner or
Date: c 9
D Ownerlcontractortagent 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 211.r L
Cash[CK #: 110
Rcvd by: L"50
Date Signed:
V5.2017
Approved Approved with changes Denied
Reason for denial:
Signed:
APPLICATION #: Df (-6 {e.? I