2. Snow and Ice Removal Exemption Form

4. I, *

   hereby request an exemption from the requirements of Beverly Municipal Code Chapter 215, § 215- 12 on the grounds that:

6. I am over the age of 65.*

   1. Yes
   2. No
8. I am physically unable to perform snow and ice removal due to physical health reasons.*

   1. Yes
   2. No
10. Due to financial hardship, I am unable to hire someone to do so.*

    1. Yes
    2. No
12. Address*
14. Phone Number*
16. Email Address (optional)
18. Electronically signed under pains and penalties of perjury:*

20. Please note that this exemption is not effective unless this form is received and signed with approval by an authorized City employee. You will receive an email when the exemption is effective.

Leave This Blank:


22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field