HomeMy WebLinkAbout22-E018 1 Katharyn Michael Roadnn TOWN OF YARMOUTH
ECE _ 1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext 1292—Fax (508) 398-0836
MAR 0 3 2022 E
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D 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.
Tyrie or print legibly:
Address of proposed work:
Map/Lot #
Owners Phone #:
r
All applications must be s mitted by owner or accompanied by letter from owner approving submittal application.
Mailing address: �j ��� 4 /(� 4 QP Year built fljll��
Email: l��a,'�t e �J)''���/ �•{'�.QrjF Preferred notification method: V Phone ail
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A9enUContractor:
Mailing Address
Emaii.
Phone #
Preferred notification method: Phone Email
Description of Proposed Work (Additional_pages may be attached if necessary):
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Signed (Owner or agent): pate:
➢ 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 X12.1"
Amount -;�0• 0
Cash/CK #. Cw
Revd by: r
Date Signed:
V5 2017
Approved Approved with changes
Reason for denial.
Signed:
Denied
APPLICATION #: ap
ECEIVED
MAR 0 3 2022
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