23-E060 47 Nickerson Farm Way ApprovedYAR D �Ui h T13PA CLERK
° TOWN OF YARMOUTH
1146 ROUTE 28, SOUTH YARMOUTH, MA 02664-4451
Telephone (508) 398-2231 Ext. 1292- Fax (508) 398-0836
OLD 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.
Type or print legibly:
Address of proposed work: 47
Nickevaon +cxv W Map/Lot # It $ / 7- 3 , Z
Owners): Dcxn:r-l Chr;:-+r)ytn5 Phone#: 5GD-905L"20101S;�
All applications must be submitted by owner or accompanied by letter from owner approving submittal of application.
Mailing address: 2-7 Pnu Kept -c9 c West w•.4 c,'-c. 13 Year built: 20i 3
Email clomcig d —4k 91014—cnw% Preferred notification method: Phone ✓ Email
Agent/Contractor: Shareltne inc, `Chr,SPhone #: 5o8-&K1-q_79
Mailing Address: 32 A me ir+c
Henri,$. vv'%A 0z&is La
Email: d� I 19 S h ore I i ne P uc is i n c. con Preferred notification method: I �!] Phone
Description of Proposed Work (Additional pages may be attached If necessary):
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Signed (Owner or agent): &43 ; cf """"' Date: 07/1Y/10 z 3
➢ Ownerlcontractorlagent is aware that a permit may be required from the Building Department. (Check other departments, also.)
➢ This certificate is good for one year from approval date or upon date of expiration of Building Permit, whichever date shall be later.
For Committee use only.
Date: It 101 r7 -_
Amount A2j CD
Cash/CK #:
Rcvd by: l�
—I/— Approved Approved with changesFA—PPRQ i fD
Reason for denial:
Date Signed:-7/1Signed: xr "� e +'Z1
v5.2017 RECEIVED
JUL 18 2023
YAHMOUTI-i
Y
APPLICATION #: 93-rWy
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APPROVED
JUL 18 2023
YARMOUTH
OLD KING'S HIGHWAY
32 Anitr(can Way -South Ownis, MA 0260 -PH : 504 432.3445 Fax: 50$ 432-0170
Utter of Authority
This letter confirms that I give permission to Shoreline Pools Inc. of Dennis, MA
authority to act as my agent with regard to all permit & historical applications for
the installation of a private in -ground swimming pool located at the address of:
Any questions {Tease contact fine at
(96,G) Sc;-yu35
Print Fume Shoreline Rep,
Shoreline Pool Rep.
Gate: _?1_2 /Zoy 3
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Custorner Print Name
Customer Signature
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