14-E040 Skipper Lane ApprovedYARMOUTH OLD KING'S HIGHWAY REGIONAL HISTORIC
DISTRICT COMMITTEE
1146 ROUTE 28, SOUTH YARMOUTH, MA
= Telephone (508) 398-2231 Ext. 1292 F pfij1
o Colleen McLaughlin, Office Ad inistrator
(cmclaughlina@yarmouth. a.us)jUN 112014
YARV"H
OLD ti(1rkGS }t!G}-l1iVAY
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 APPLICATION FORM & ACCOMPANYING INFORMATION
(INCLUDING PHOTOS).
Type or print legibly: 115k,
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���Address
of proposed work:Map/Lot
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Owner(s):
Mailing ad
Email:
Aaenticontractor:
Mailing Address:. ZZ
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Email: U/
Descr
Phony #: �.. � ✓
Year built:
Preferred notification method: X Phone Email
Phone #:
Preferred notification method: Phone
i
ption of Proposed Work(Additional Pa2es may be attached if necessa
w":
Signed (Owner or agent):
Date: i Z//Z�
Photos showing all sides of building MUST accompany application.
Ownerlcontracterlagent 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:
Received by OK
Date:
Cash/Check
Rcvd by:
_1//Approved
Reason for denial:
Approved with changes
Date signed: Z
Signed:
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