10-900 National Register of Historic Places Registration Form

United States Department of the Interior

National Park Service / National Register of Historic Places Registration Form

NPS Form 10‑900 OMB No. 1024‑0018

Name of Property County and State

United States Department of the Interior

National Park Service

National Register of Historic Places Registration Form

This form is for use in nominating or requesting determinations for individual properties and districts. See instructions in National Register Bulletin, How to Complete the National Register of Historic Places Registration Form. If any item does not apply to the property being documented, enter "N/A" for "not applicable." For functions, architectural classification, materials, and areas of significance, enter only categories and subcategories from the instructions.

1. Name of Property

Historic name: ______________________________________________

Other names/site number: ______________________________________

Name of related multiple property listing:

___________________________________________________________

(Enter "N/A" if property is not part of a multiple property listing

____________________________________________________________________________

2. Location

Street & number: _____________________________________________

City or town: ____________ State: ____________ County: ____________

N

ot For Publication: Vicinity:

____________________________________________________________________________

3. State/Federal Agency Certification

As the designated authority under the National Historic Preservation Act, as amended,

I hereby certify that this nomination ___ request for determination of eligibility meets the documentation standards for registering properties in the National Register of Historic Places and meets the procedural and professional requirements set forth in 36 CFR Part 60.

In my opinion, the property ___ meets ___ does not meet the National Register Criteria. I recommend that this property be considered significant at the following
level(s) of significance:

___national ___statewide ___local

Applicable National Register Criteria:

___A ___B ___C ___D

Signature of certifying official/Title: Date

______________________________________________

State or Federal agency/bureau or Tribal Government

In my opinion, the property meets does not meet the National Register criteria.

Signature of commenting official: Date

Title : State or Federal agency/bureau
or Tribal Government

______________________________________________________________________________

4. National Park Service Certification

I hereby certify that this property is:

entered in the National Register

determined eligible for the National Register

determined not eligible for the National Register

removed from the National Register

other (explain:) _____________________

______________________________________________________________________

Signature of the Keeper Date of Action

____________________________________________________________________________

5. Classification

Ownership of Property

(Check as many boxes as apply.)

P

rivate:

Public – Local

Public – State

Public – Federal

Category of Property

(Check only one box.)

Building(s)

District

Site

Structure

Object

Number of Resources within Property

(Do not include previously listed resources in the count)

Contributing Noncontributing

_____________ _____________ buildings

_____________ _____________ sites

_____________ _____________ structures

_____________ _____________ objects

_____________ ______________ Total

Number of contributing resources previously listed in the National Register _________

____________________________________________________________________________

6. Function or Use

Historic Functions
(Enter categories from instructions.)

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Current Functions
(Enter categories from instructions.)

___________________

___________________

___________________

___________________

___________________

___________________

_____________________________________________________________________________

7. Description

Architectural Classification

(Enter categories from instructions.)

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Materials: (enter categories from instructions.)

Principal exterior materials of the property: ________________________

Narrative Description

(Describe the historic and current physical appearance and condition of the property. Describe contributing and noncontributing resources if applicable. Begin with a summary paragraph that briefly describes the general characteristics of the property, such as its location, type, style, method of construction, setting, size, and significant features. Indicate whether the property has historic integrity.)

______________________________________________________________________________

Summary Paragraph

______________________________________________________________________________

Narrative Description

_________________________________________________________________

8. Statement of Significance

Applicable National Register Criteria

(Mark "x" in one or more boxes for the criteria qualifying the property for National Register

listing.)

1. P

   roperty is associated with events that have made a significant contribution to the broad patterns of our history.
   
   

2. Property is associated with the lives of persons significant in our past.
   
   

3. P

   
   

   roperty embodies the distinctive characteristics of a type, period, or method of construction or represents the work of a master, or possesses high artistic values, or represents a significant and distinguishable entity whose components lack individual distinction.
   
   

4. Property has yielded, or is likely to yield, information important in prehistory or history.

Criteria Considerations

(Mark “x” in all the boxes that apply.)

1. O

   wned by a religious institution or used for religious purposes
   

2. R

   emoved from its original location
   
   

3. A

   
   

   birthplace or grave
   
   

4. A cemetery
   
   

5. A

   reconstructed building, object, or structure
   
   

6. A

   commemorative property
   
   

7. Less than 50 years old or achieving significance within the past 50 years

Areas of Significance
(Enter categories from instructions.)

___________________

___________________

___________________

___________________

___________________

___________________

___________________

Period of Significance

___________________

___________________

___________________

Significant Dates

___________________

___________________

___________________

Significant Person
(Complete only if Criterion B is marked above.)

___________________

___________________

___________________

Cultural Affiliation

___________________

___________________

___________________

Architect/Builder

___________________

___________________

___________________

Statement of Significance Summary Paragraph (Provide a summary paragraph that includes level of significance, applicable criteria, justification for the period of significance, and any applicable criteria considerations.)

______________________________________________________________________________

Narrative Statement of Significance (Provide at least one paragraph for each area of significance.)

______________________________________________________________________________

9. Major Bibliographical References

Bibliography (Cite the books, articles, and other sources used in preparing this form.)

___________________________________________________________________________

Previous documentation on file (NPS):

____ 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 Buildings Survey #____________

____ recorded by Historic American Engineering Record # __________

____ recorded by Historic American Landscape Survey # ___________

Primary location of additional data:

____ State Historic Preservation Office

____ Other State agency

____ Federal agency

____ Local government

____ University

____ Other

Name of repository: _____________________________________

Historic Resources Survey Number (if assigned): ________________

______________________________________________________________________________

10. Geographical Data

Acreage of Property _______________

Use either the UTM system or latitude/longitude coordinates

Latitude/Longitude Coordinates

Datum if other than WGS84:__________

(enter coordinates to 6 decimal places)

1. Latitude: Longitude:
   
   

2. Latitude: Longitude:
   
   

3. Latitude: Longitude:
   
   

4. Latitude: Longitude:

Or

UTM References

Datum (indicated on USGS map):

NAD 1927 or NAD 1983

1. Zone: Easting: Northing:
   
   

2. Zone: Easting: Northing:
   
   

3. Zone: Easting: Northing:
   
   

4. Zone: Easting : Northing:

Verbal Boundary Description (Describe the boundaries of the property.)

Boundary Justification (Explain why the boundaries were selected.)

______________________________________________________________________________

11. Form Prepared By

name/title: __________________________________________________________

organization: ________________________________________________________

street & number: _____________________________________________________

city or town: _________________________ state: ____________ zip code:___________

e-mail________________________________

telephone:_________________________

date:_____________________________

___________________________________________________________________________

Additional Documentation

Submit the following items with the completed form:

• Maps: A USGS map or equivalent (7.5 or 15 minute series) indicating the property's location.
  

• Sketch map for historic districts and properties having large acreage or numerous resources. Key all photographs to this map.

• Additional items: (Check with the SHPO, TPO, or FPO for any additional items.)

Photographs

Submit clear and descriptive photographs. The size of each image must be 1600x1200 pixels (minimum), 3000x2000 preferred, at 300 ppi (pixels per inch) or larger. Key all photographs to the sketch map. Each photograph must be numbered and that number must correspond to the photograph number on the photo log. For simplicity, the name of the photographer, photo date, etc. may be listed once on the photograph log and doesn’t need to be labeled on every photograph.

Photo Log

Name of Property:

City or Vicinity:

County: State:

Photographer:

Date Photographed:

Description of Photograph(s) and number, include description of view indicating direction of camera:

1 of ___.

Paperwork Reduction Act Statement: This information is being collected for applications to the National Register of Historic Places to nominate properties for listing or determine eligibility for listing, to list properties, and to amend existing listings. Response to this request is required to obtain a benefit in accordance with the National Historic Preservation Act, as amended (16 U.S.C.460 et seq.). We may not conduct or sponsor and you are not required to respond to a collection of information unless it displays a currently valid OMB control number.

Estimated Burden Statement: Public reporting burden for each response using this form is estimated to be between the Tier 1 and Tier 4 levels with the estimate of the time for each tier as follows:

Tier 1 – 50 hours

Tier 2 – 100 hours

Tier 3 – 150 hours

Tier 4 – 250 hours

The above estimates include time for reviewing instructions, gathering and maintaining data, and preparing and transmitting reports. Send comments regarding these estimates or any other aspect of the requirement(s) to the Service Information Collection Clearance Officer, National Park Service, 1849 C St. NW (2605 - MS1242), Washington, DC 20240-0001

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