HomeMy WebLinkAboutSite Access AuthorizationDEPARTMENT
OF
CONSERVATION
site accej j authowzation Jts- awt
If the applicant is not the property owner, please submit this form with your application. The owner
must be sent a copy of the application on the same day it is filed with this office.
Property Address: 7� 9 G e---� ( lzo ad '(6, r`vv-,o % P c (-J
Assessors Map/Lot: SSeSSc)� 5 2-�P ?Cr C->� �� • I
I (we) hereby authorize the individual members of the Yarmouth Conservation Commission and its
agents to enter upon the referenced property for the purpose of gathering information regarding the
application filed with the Commission pursuant to the Wetlands Protection Act (M.G.L. Ch. 131, s.
40) and/or the Yarmouth Wetlands Protection Bylaw (Chapter 143).
Authorized Signature: Date: � 3'
Please Print Name: �y l"'^C'
If other than owner, please state whether tena tfn age t or other:
Mailing Address:
(.T,qC) -ThOJSq"" 04-5 Pr-i i -
Phone: 9 1 `{ - 3 2-3 - 0 U 0 .S Cell:
Email: Fax:
( ".."L%(0@ CaC2cv A W• a„dg,
cven
Yarmouth Conservation Commission • 1146 Route 28 • South Yarmouth, MA 02664-4492
Tel. (508)-398-2231 Ext. 1288 • Fax (508)-398-0836 • TTD# (508) 398-2231