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1146 ROUTE 28, SOUTH YARMOUTH, MASSACHUSIETTS 02064
Telephone (508) 398-2231 Ett.1292 - Fax (508) 398-0836
OLD KING'S HIGHWAY REGIONAL HISTORIC DISTRICT COMMITTEE
MINOR CHANGE REQUEST
Original CIA Information #If-maDate J /9 &OI/
Address of Proposed Work
Owner's Name
Owner's Mailing Address
Owner's Phone #/Email
Agent's Name
Agent's Phone #/Email
Please describe proposed change and attach plans/photos (as necessary):
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Signature
Date
Am [nor 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.
V'�Approved by OKH
Denied by OKH New CIA required? Yes No
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APPROVED
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YARMOUTH
OLD KINGS HIGHWAY