21-A088-A1 57 Pheasant Cove Circle=YTOWN OF YARMOUTH
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1146 ROUTE 28, SOUTH YARMOUTH,MASSACHUSETTS 02664-4451
Telephone (508) 398-2231 Ext. 1292 Fax (508) 398-0836
" OLD KING'S HIGH«'AI' HISTORIC DISTRICT COINMITTEE
AMENDMENT FORM
("MINOR CHANGE REQUEST")
A minor change request must be submitted within one year of the original approval date or while the work is still in
progress. Only a minor change may be approved by the Committee without the filing of a new application.
PLEASE TYPE OR'PRINT LEGIBLY
Original Application #: di /"w Original Approval Date: (044-121
Address of proposed work: �j 1 Q -m �- 6ove- [,
Owner(s): ?1f' Lii to Phone #: 51gS" Ot .3
I'v-1ai!ing address:
Email V ,1.. Wk- 2S12 11') Preferred notification method:—Phone V Email US Mail
Agent/Contractor: w),flt J -e 1r' Phone #: Vrr ,Y
Email: Preferred notification method: Phone Email
Please describe proposed change(s) and attach plans/photos (as necessary):
Signed (Owner or Agent)
Approved by OKH
Reason for Denial:
Signed OKH Chairman
11/2015
Denied by OKH
New CIA required?
Date I &q ).a,
Date
Yes No
AMENDMENT # I —A OW ,A I