APPENDIX A

MASSACHUSETTS HISTORICAL COMMISSION

220 MORRISSEY BOULEVARD

BOSTON, MA 02125

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).

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 S)))))))))Q acres Productive Resources: Wetland S))))))))))Q acres Agriculture S)))))))))Q acres Floodplain S)))))))Q acres Forestry S))))))))))))Q acres Open space S)))))))Q acres Mining/Extraction S)))Q acres Developed S))))))))Q acres Total Project Acreage S)))Q acres

What is the acreage of the proposed new construction? S)))))))))Q 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.

S))))))))))))))))))))))))))))))))))))))))Q S)))))))))))))))))))))))))Q 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 through 27C as amended by St. 1988, c. 254.