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DEPARTMENT
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CONSERVATION
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: 3 Windermere Road} West Yarmouth
Assessors Map/Lot: 21/47
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:
Please Print Name: Robin W. Wilcox, PLS
If other than owner, please state whether tenant, agent, or other: Agent
Mailing Address:
P.O. Box 713
South Dennis, MA 02660
Phone: 508-385-6900 Cell: 508-367-4631
Email:sweetsereng aol_comFax:508-385-6991
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