Evaluation Of Significance Form printable pdf download

MASSACHUSETTS HISTORICAL COMMISSION

STATE HISTORIC REHABILIATION TAX CREDIT PROGRAM

HISTORIC PRESERVATION CERTIFICATION APPLICATION

PART 1 – EVALUATION OF SIGNIFICANCE

Project No.: ____________________________

Instructions: Read the instructions carefully before completing application. No certification will be made unless a completed application form has

been received. Type or print clearly in black ink. If additional space is needed, use continuation sheets or attach blank sheets. A copy of this form

may be provided to the Department of Revenue. The decision by the Massachusetts Historical Commission with respect to certification is made on

the basis of descriptions in this application form. In the event of any discrepancy between the application form and other, supplementary material

submitted with it (such as architectural plans, drawings and specifications), the application form shall take precedence.

Name of property: ________________________________________________________________________________________________

Address of property:

Street___________________________________________________________________________________

City_________________________________________________________ State MA

Zip____________

Listed individually in the National Register of Historic Places: ___________________________ give date of listing: _______________

Located in a National Register Historic District as a contributing resource: name of District: __________________________________

Eligible for listing (previous determined by MHC): ___________________________________________________________________

Level of Significance (local, national, NHL) ________________________________________________________________________

NPS Project Number (if application for federal tax credits submitted) _____________________________________________________

No determination of eligibility (submit Form B):______________________________________________________________________

Project contact:

Name __________________________________________________________________________________________________________

Street__________________________________________ City ___________________________________________________________

State___________________ Zip____________________ Daytime Telephone Number ________________________________________

Owner:

Name___________________________________ Signature________________________________________ Date____________________

Organization _____________________________________________________________________________________________________

Social Security or Taxpayer Identification Number_______________________________________________________________________

Street___________________________________ City____________________________________________________________________

State___________________ Zip____________________ Daytime Telephone Number ________________________________________

See attachments (please list): _____________________________________________________________________________________________

_____________________________________________________________________________________________

Evaluation Of Significance Form