HomeMy WebLinkAbout22-E002 173 Route 6A�IFYqR TOWN OF YARMQ�VED
x 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext. 1292—Fax (508 398-0jVA 0 5- 2022
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 o
Qwner s):
All applications) rN
Mailing address:: }c`�
Email:
Agent/Contractor.-
Mailing
gent/Contractor:Mailing Address:
Email: 6-%W-'2
y ' J {(y't Map/Lot # IZZ, 1,70
Phone #.. qt t 1- l � '.J6to-
a- submitted by owner or accompanied by letter from owner approving submittal of application.
f Year built: WS
_
L L Preferred notification method. Phone k" Email
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Phone #: Vr
I
Preferred notification method Phone V Email
Description of ProRosed Work Additional pages may be attached iif1 necessary);
�.6y'ITJ
Signed (ONmer or agent):
Date: I /�(Jz'__
> pwner/contractorlagent is aware that a permit may he required from the Building Department. (Check other departments, also.)
➢ This certificate is good for one year from approval date or upon dale of expiration of Building Permit. whichever date shall be later.
For Committee use onty:
Date
Amount 6)•00
Cash/CK #.
Rcvd by: L' S
Date Signed
V5 2017
Approved Approved with changes
Reason for denial.
Signed:
Denied
APPLICATION #-
1222
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PLOP PLAN
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If this is a
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write in
name of street.
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