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DEPARTMENT
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CONSERVATION
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If the applicant is not the property owner, Please submit this form with your application.
must be sent a copy of the application on the same day 1t is filed with this office.
Propel Address:
Assessors Map/Lot:
A-1-11 ?6W64�5
The owner
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1(we) hereby authon'ze the individual members of the Youth Conservation Commission and its
agents to eater upon the referenced property for the purpose of gathefing information regarding the
application filed with the Commission pursuant to the Wetlands Protection Act (M. .L. Ch. 13 1, s.
40} and/or the Yarmouth Wetlands Protection Bylaw (Chapter 143).
Authorized Signature:
Please Print Larne:
- - Date:
%�i6-ire C� 2� y
If other than owner, please state whether tenant., agent, or other: 7
Mailing ddre :
Phone:
Email:
`�700`FH LA.- 0 il
�7 7�7 0Y - 7?M71 -2�7 -
Cell:
"7LY/ L (V -�j
Fax:
Youth
Conservation Commission #
1146 Route 28 * South Yarmouth,
MA
02664-4492
Tel.
1
Ext. 1288#
Fax &
TTD#
(508)
399-2231