MHC Project Notification Form950 CMR: OFFICE OF THE SECRETARY OF THE COMMONWEALTH
APPENDIX A
MASSACHUSETTS HISTORICAL COMMISSION
220 MORRISSEY BOULEVARD
BOSTON, MASS. 02125
617-727-8470, FAX: 617-727-5128
PROJECT NOTIFICATION FORM
Project Name: ________________________________________________________________________________
Location / Address: ___________________________________________________________________________
City / Town: ________________________________________________________________________________
Project Proponent
Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
City/Town/Zip/Telephone: _____________________________________________________________________
Agency license or funding for the project (list all licenses, permits, approvals, grants or other entitlements being
sought from state and federal agencies).
Agency Name Type of License or funding (specify)
Project Description (narrative):
Does the project include demolition? If so, specify nature of demolition and describe the building(s) which
are proposed for demolition.
Does the project include rehabilitation of any existing buildings? If so, specify nature of rehabilitation
and describe the building(s) which are proposed for rehabilitation.
Does the project include new construction? If so, describe (attach plans and elevations if necessary).
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950 CMR: OFFICE OF THE SECRETARY OF THE COMMONWEALTH
APPENDIX A (continued)
To the best of your knowledge, are any historic or archaeological properties known to exist within the
project’s area of potential impact? If so, specify.
What is the total acreage of the project area?
Woodland ______________acres Productive Resources:
Wetland________________acres Agriculture _________________acres
Floodplain______________acres Forestry ___________________acres
Open space______________acres Mining/Extraction ___________acres
Developed ______________acres Total Project Acreage_________acres
What is the acreage of the proposed new construction? _________________acres
What is the present land use of the project area?
Please attach a copy of the section of the USGS quadrangle map which clearly marks the project location.
This Project Notification Form has been submitted to the MHC in compliance with 950 CMR 71.00.
Signature of Person submitting this form: _________________________________Date: ____________________
Name: ______________________________________________________________________________________
Address: ____________________________________________________________________________________
City/Town/Zip: ______________________________________________________________________________
Telephone: __________________________________________________________________________________
REGULATORY AUTHORITY
950 CMR 71.00: M.G.L. c. 9, §§ 26-27C as amended by St. 1988, c. 254.
7/1/93 950 CMR - 276