HomeMy WebLinkAbout12-E075 395 Route 6AYARMOUTH OLD KING'S HIGHWAY REGIONAL HISTORIC
DISTRICT COMMITTEE
1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSETTS 02664
Telephone (508) 398-2231 Ext. 1292 Fax (508) 398-0836
Colleen McLaughlin, Office Administrator
(cmelaughlln @yarmouth.ma.us)
CERTIFICATE OF EXEMPTION
Application is hereby made for the issuance of a Certificate of Exemption under Sections 6 and 7 of Chapter 740,
Acts of 1973, as amended, for the proposed work as described below and on plans, drawings, or photographs
accompanying this application. PLEASE SUBMIT TWO W COPIES OF APPLICATION FORM &
ACCOMPANYING INFORMATION (INCLUDING PHOTOS).
Type or print legibly:
Address of proposed work, � 5 & `E''4 ti`} �Ll� +� Map /Lot #
Owners : 11ft'P-+J- 'tel \16 Prty _ Phone #: " Itk
Mailing address;
Year built:
Email: � -
n�
�Z%_tJ W v CQu.CASr
Preferred notification method: Phone
Agent/contractor:
Mailing Address:
Email
Phone #: "WDS �� 5 4q�
Email: 1 `Z Preferred notification method: Phone Email
Description of Proposed Work (Additional Rapes may be attached if necessary):
4i�,Acc- -a� AQjzkD v�trik ",—,ecs- S"Lis,
Signed Owner oragent): CoLLQYAC:'„, U H.
g �OLD KiNG'S �HIGHWAY te: � O�
9 Photos (2 sets) showing all sides of building MUST accompany application.
Owner/contractor/agent is aware that a permit may be required from the Building Department. (Check other departments, also.)
A 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 oni
Received by OKH:
Date:
Cash/Check #: _
Rcvd by.,
Approved Approved with changes
Reason for denial:
Date signed: 7 2�i� Signed:
PPROVED
+!'�! 07 2012
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