Historic Landmark Registration Form

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Historic Landmark Registration Form Powered By Docstoc
					Town of Concrete Historic Preservation Commission      45672 Main Street/P.O. Box 39   Concrete, WA 98237   360.853.8401



        Concrete Historic Landmark/Structure Registration Form
        This form is used to nominate properties to the Town of Concrete Register of Historic Places.

         Complete each item by entering the requested information.

If you have questions, please ask.

1. Name of Property

Current Name: ________________________________ Historic Name: __________________________

Other Names: _________________________________________________________________________

2. Location

Street Address: _______________________________                    Town, State, Zip: Concrete, WA 98237_______

Parcel Number: ________________

3. Classification

Ownership of Property:  Private                      Public-Local        Public-State        Public-Federal

 Building(s)             District                  Site                Structure            Object

4. Owner of Property

Name: ________________________________________ Telephone: _____________________________

Mailing Address: ______________________________________________________________________

Email: _______________________________________________________________________________

5. Form Prepared By:

Name: ________________________________________ Telephone: ____________________________

Organization: ___________________________________ Title: _________________________________

Mailing Address: ______________________________________________________________________

Email: _______________________________________________________________________________




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6. Description of Property

Describe the present and historical physical appearance of the property: (attach additional sheets if necessary)




7. Statement of Significance

Applicable Designation Criteria
(Mark “X” in all the boxes that apply.)

        1. It is associated with events that have made a significant contribution to the broad patterns of
         national, state or local history.
        2. It embodies the distinctive architectural characteristic of a type, period, style or method of
         construction, or represents a significant and distinguishable entity whose components may lack
         individual distinction.
        3. It is an outstanding work of a designer, builder or architect who has made a sustainable
         contribution to the art.
        4. It exemplifies or reflects special elements of the Town’s cultural, social, economic, political,
         aesthetic, engineering or architectural history.
        5. It is associated with the lives of persons significant in national, state or local history.
        6. It has yielded or is likely to yield important archaeological information.
        7. It is a building or structure removed from its original location but which is significant
         primarily for architectural value, or which is the only surviving structure significantly
         associated with an historic person or event.
        8. It is a birthplace or grave of a person of outstanding importance and is the only surviving
         structure or site associated with that person.
        9. It is a cemetery that derives its primary significance from age, from distinctive design features,
         or from association with historic events or cultural patterns.
        10. It is a reconstructed building that has been executed in a historically accurate manner on the
         original site.
        11. It is a creative and unique example of folk architecture and design created by person or
         formally trained in the architectural or design professions, and which does not fit into formal
         architectural or historical categories.




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Areas of Significance: (attach additional sheets if necessary)




Period of Significance: ____________________________ Significant Dates: ________ to ________

Significant Person: (complete if criterion #3 is marked above) ________________________________

Architect/Engineer: _________________________________ Builder: __________________________

State the significance of the property and reasons from items 1 -11 above in section 7: (attach
additional sheets if necessary)




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8. Major Biological References:

Bibliography: cite books, articles, and other sources used in preparing this form below. (attach
additional sheets if necessary)




9. Geographical Data:

Acreage of Property: _______________________

UTM References: (Universal Transverse Mercator)

A │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
   Zone                Easting                               Northing

B │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
   Zone                Easting                               Northing

C │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
   Zone                Easting                               Northing

D │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
   Zone                Easting                               Northing

Legal Description:




10. Additional Required Documentation:




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Please list maps and photograph log in the order of attachments: (attach additional sheets if necessary)




Signature of Owner(s)

OWNER CONSENT FOR DESIGNATING AND LISTING

I (we) consent to the listing of the above property on the Town of Concrete Historic Landmark Register. I
(we) also certify being the legal owner(s) of the above property.


Owner Signature __________________________Print Name______________________ Date _________

Owner Signature __________________________Print Name______________________ Date _________

Owner Signature __________________________Print Name______________________ Date _________




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                                                STAFF USE ONLY
1. Number of Resources within the Property:

Contributing                             Non-Contributing
                                                                    Buildings
                                                                    Sites
                                                                    Structures
                                                                    Objects
                                                                    Totals

Name of related multiple property listing: __________________________________________________
(enter N/A if property is not part of a multiple property listing)

Number of contributing resources previously designated as Town of Concrete Historic Landmarks: _____

2. Function or Use:

Historic Functions




Current Functions




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3. Description

Architectural Classification




Materials: ____________________________________________________________________________

Foundation: _________________________________ Walls: ___________________________________

Roof: _____________________________________ __Other: ___________________________________



4. Major Bibliographical Reference Documentation Checklist:

Previous Documentation on File

 Included in Town of Concrete Historic Resource Inventory

 Previously designated a Town of Concrete Landmark

 Listed in the Washington State Register of Historic Places

 Preliminary determination of individual listing

 (36 CFR 67) has been requested

 Previously listed in the National Register

 Previously determined eligible by the National Register

 Designated a National Historic Landmark

 Recorded by Historic American Building, Survey #_______

 Recorded by Historic American Engineering, Record #_________




Primary Location of Additional Data




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 State Historic Preservation Office

 Other State Agency

 Federal Agency

 Local Government

University

 Other _______________________________________________



5. Boundary Justification (if needed):




Received: ___________________

             Town of Concrete Historic Preservation Commission Recommendation/Decision:

In the opinion of the Town of Concrete Historic Preservation Commission, the property does NOT
meet the Town of Concrete Landmark Register criteria.

Commission Chair Signature: ______________________________________________Date: __________

Town Planner Signature: __________________________________________________Date: __________

The Town of Concrete Historic Preservation Commission has reviewed the referenced application and
does hereby by recommend to the Town of Concrete Town Council approval of said property for
placement on the Town of Concrete Historic Landmark Register.

Commission Chair Signature: ______________________________________________Date: __________



Town Planner Signature: __________________________________________________Date: __________




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Town of Concrete Town Council Action:

The Town of Concrete Town Council gave its approval in the Town Council meeting of (Date)
__________

We hereby certify that this property has been listed in the Town of Concrete Register of
Historic Places:


___________________________________________________________
Judd Wilson - Mayor, Town of Concrete


___________________________________________________________
David Soule - Chair, Town of Concrete Historic Preservation Commission

=====================================================================================
Town of Concrete Town Council denied the application for placement on the Town of Concrete Register
of Historic Places:

___________________________________________________________
Judd Wilson – Mayor, Town of Concrete


___________________________________________________________
David Soule – Chair, Town of Concrete Historic Preservation Commission




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