Form 10-168e HPCA SHPO Review & Recommendation Sheet Rehabilitation P

NPS Form 10-168e (Rev. 2019) OMB Control No. 1024-0009

N ational Park Service

HISTORIC PRESERVATION CERTIFICATION APPLICATION

STATE HISTORIC PRESERVATION OFFICE

REVIEW & RECOMMENDATION SHEET
PART 2 / PART 3 – REHABILITATION

SECTION 1. APPLICATION INFORMATION						PROJECT NUMBER
Historic Property Name __________________________________________________________
Property Address _________________________________________________________
Certified Historic Structure (select one) ☐ Yes ☐ Pending
☐		Part 2						SHPO REVIEW SUMMARY
		☐		Preliminary consultation (date)		☐		No outstanding concerns
		☐		Applying for state tax credit		☐		In-depth NPS review requested
☐		Part 3 (Part 2 previously reviewed)				☐		Applicant informed of SHPO recommendation
		☐		Completed rehabilitation work conforms to work previously approved
		☐		Completed rehabilitation work differs substantively from work previously approved (describe divergences from Part 2 scope of work in Section 5)
☐		Part 3 (Part 2 not previously reviewed)				Application received (date)
☐		Amendment (applicant signature date )				Additional information requested (date/s)
☐		Request for an advisory determination for a phase				Complete information received (date)
☐		Property visited by SHPO staff (date/s):				Transmitted to NPS (date)
Before , during , and/or after rehab.
SECTION 2. APPLICATION MATERIALS
Sent previously: ☐ Photographs ☐ Other (list)
Attachments: ☐ Photographs ☐ Rolled plans ☐ Flat plans, large size ☐ Flat plans, 11” x 17” or smaller ☐ Other (list)
Sent separately: ☐ Photographs ☐ Rolled plans ☐ Flat plans, large size ☐ Flat plans, 11” x 17” or smaller ☐ Other (list)
Documentation remaining on file in SHPO (e.g., masonry repointing samples, specifications)
SECTION 3. SHPO RECOMMENDATION
, who meets the Secretary of the Interior’s Professional Qualification Standards, has reviewed this application.
This rehabilitation work (select only one):
☐		meets the Standards.
☐		meets the Standards with concerns.
☐		meets the Standards only if the attached conditions are met (Part 2 and Amendments only).
☐		does not meet Standard number(s) and for the reasons described in Section 5.
☐		does not meet Standard number(s) as completed, but could be brought into conformance with the Standards if the remedial work recommended in Section 5 is completed (Part 3 only).
☐		warrants denial for lack of information.
☐		is being forwarded without recommendation.
				Date		State Historic Preservation Office Signature
				This is a review sheet only and does not constitute an official certification of rehabilitation.
	SECTION 4. ISSUES
	☐		Alteration of significant exterior features or surfaces		☐		Alteration, removal, or covering of significant interior features or finishes
	☐		Window replacement		☐		Changes in significant interior plan, spaces, or circulation patterns
	☐		Additions, including rooftop		☐		Other (explain)
	☐		Extensive site work, adjacent new construction, or demolition of adjacent structures
	SECTION 5. SHPO EVALUATION
	Explain the recommendation and any concerns, particularly issues checked in Section 4. Where denial is recommended, explain fully. For Part 3s, describe any work that differs substantially from the approved work. For Part 3s that do not meet the Standards as completed, describe remedial work, if any that could enable the project to meet the Standards. Comment on notable aspects of the project, such as technical design innovations or creative solutions.
	SECTION 6. NATIONAL PARK SERVICE EVALUATION
			Date				National Park Service Signature

Historic Property Name	Project Number
Property Address
The rehabilitation of this property as described in the Historic Preservation Certification Application will meet the Secretary of the Interior’s Standards for Rehabilitation provided that the following condition(s) is/are met:
Photographs documenting that the conditions have been met must be submitted with the Request for Certification of Completed Work. Any substantive change in the work as described in the application should be brought to the attention of the State Historic Preservation Office and the National Park Service in writing, using the Amendment/Advisory Determination form, prior to execution to ensure that the proposed project continues to meet the Standards.
Date	State Historic Preservation Office Signature
The National Park Service has determined that this project will meet the Secretary of the Interior Standards for Rehabilitation if the condition(s) listed above are met.
Date	National Park Service Signature

NOTICES

Privacy Act Statement

Authority: 26 U.S. Code § 47 - Rehabilitation credit; 26 U.S. Code § 170 - Charitable, etc., contributions and gifts.

Purpose: To enable the Secretary of the Interior to evaluate the historic significance of structures and whether the rehabilitation of such structures preserves their historic character. The primary use of this information by the Secretary of the Interior will be to certify to the Secretary of the Treasury that the applicant is eligible for Federal tax incentives for historic preservation. This application is used by the Internal Revenue Service to confirm that applicants for the tax incentives have obtained the certification concerning historic structures and historic rehabilitations that are required by law.

Routine uses: The information will be used by the National Park Service and the State Historic Preservation Offices and disclosed to the Internal Revenue Service to determine if the applicant is eligible for Federal tax incentives.

Disclosure: Voluntary, however, failure to provide the requested information may prevent or impede you from receiving consideration for the requested benefit.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) through the State Historic Preservation Officer in order to enable the Secretary of the Interior to gain the benefit of the State review of applications for Federal tax incentives for historic preservation by owners of historic properties. Information collected on this form, including names and all written comments, is subject to disclosure. All applicable parts of the form must be completed in order to receive consideration for the requested benefit. A Federal agency may not conduct or sponsor, and a person is not required to respond a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection and assigned it control number 1024-0009.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 5 hours per response when completed in association with NPS Form 10-168a (Part 2); 3 hours per response when completed in association with NPS Form 10-168b (Amendment / Advisory Determination); and 4 hours per response when completed in association with NPS Form 10-168c (Part 3), including the time it takes to read, gather and maintain data, review instructions, and complete the form. Direct comments regarding these burden estimates, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 1201 Oakridge Drive, Fort Collins, CO 80525. Please do not send your form to this address.

Records Retention Statement

Permanent. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Resource Management and Lands (Item 1.A.2) (N1-79-08-1))

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