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 How to Complete the National Register of Historic Places Registration Form (National Register Bulletin 16A). Complete each item by marking "x" in the appropriate box or by entering the information requested. 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. Place additional entries and narrative items on continuation sheets (NPS Form 10-900a). Use a typewriter, word processor, or computer, to complete all items.

1. Name of Property

historic name __________________________________________________________________________

other names/site number _______________________________________________________________________________

2. Location

street & number ___________________________________________________ not for publication ___

city or town ____________________________________________________________ vicinity ___

state _________________ code ____ county ______________________ code _____ zip code _________

3. State/Federal Agency Certification

As the designated authority under the National Historic Preservation Act of 1986, 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 [ nationally / statewide / locally ] . ( [ See continuation sheet for additional comments. ] )

__________________________________________________________ _________________
Signature of certifying official Date

______________________________________________________________________________
State or Federal agency and bureau

 

In my opinion, the property [ meets / does not meet ] the National Register criteria. ( [ See continuation sheet for additional comments. ] )

__________________________________________________________ _________________
Signature of commenting or other official Date

_______________________________________________________________________________
State or Federal agency and bureau

 

4. National Park Service Certification

I, hereby certify that this property is: Signature of Keeper Date of Action

___ entered in the National Register

___ See continuation sheet. __________________________________________________________________

___ determined eligible for National Register

___ See continuation sheet. __________________________________________________________________

___ determined not eligible for the National Register

___ removed from the National Register

___ other (explain): __________________________ ______________________________________________________________________

5. Classification

Ownership of Property: Category of Property Number of Resources within Property

(Check as many boxes as apply) (Check only one box) (Do not include previously listed resources in the count.)

___ private ___ building(s) Contributing Noncontributing

___ public-local ___ district ______ _____ buildings

___ public-State ___ site ______ _____ sites

___ public-Federal ___ structure ______ _____ structures

___ object ______ _____ objects

______ _____ Total

Name of related multiple property listing Number of contributing resources previously

(Enter "N/A" if property is not part of a multiple property listing.) listed in the National Register

_____________________________________________ __________________________________________________

6. Function or Use

Historic Functions Current Functions

(Enter categories from instructions) (Enter categories from instructions)

Cat: _________________________________________: __________________________________________________

______________________________________________ __________________________________________________

______________________________________________ __________________________________________________

______________________________________________ __________________________________________________

______________________________________________ __________________________________________________

Sub __________________________________________ __________________________________________________

______________________________________________ __________________________________________________

______________________________________________ __________________________________________________

7. Description

Architectural Classification Materials

(Enter categories from instructions) (Enter categories from instructions)

______________________________________________ foundation _________________________________________

______________________________________________ roof ______________________________________________

______________________________________________ walls _____________________________________________

__________________________________________________

other _____________________________________________ __________________________________________________

Narrative Description

(Describe the historic and current condition of the property on one or more continuation sheets.)

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)

___ A: Property is associated with events that have made a significant contribution to the broad patterns of our history.

___ B: Property is associated with the lives of persons significant in our past.

___ C: Property 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.

___ D: Property has yielded, or is likely to yield information important in prehistory or history.

Criteria Considerations

(Mark "X" in all the boxes that apply.)

Property is:

___ A: owned by a religious institution or used for religious purposes.

___ B: removed from its original location.

___ C: a birthplace or a grave.

___ D: a cemetery.

___ E: a reconstructed building, object, or structure.

___ F: a commemorative property.

___ G: less than 50 years of age or achieved significance within the past 50 years.

Areas of Significance

(Enter categories from instructions)

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Period of Significance

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Significant Dates

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Significant Person

(Complete if Criterion B is marked above)

______________________________________________

______________________________________________

Cultural Affiliation

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Architect/Builder

______________________________________________

______________________________________________

______________________________________________

Narrative Statement of Significance

(Explain the significance of the property on one or more continuation sheets.)

9. Major Bibliographical References

Bibliography

(Cite the books, articles, and other sources used in preparing this form on one or more continuation sheets.)

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 National Register

___ designated a National Historic Landmark

___ recorded by Historic American Buildings Survey

# __________

___ recorded by Historic American Engineering Record

# __________

 

Primary Location of Additional Data

___ State Historic Preservation Office

___ Other State agency

___ Federal agency

___ Local government

___ University

___ Other

Name of repository: ______________________________________________

10. Geographical Data

Acreage of Property ___________

UTM References

(Place additional UTM references on a continuation sheet)

1 | __| __| | __| __| __| __| __| __| | __| __| __| __| __| __| __| 3 | __| __| | __| __| __| __| __| __| | __| __| __| __| __| __| __|

Zone Easting Northing Zone Easting Northing

2 | __| __| | __| __| __| __| __| __| | __| __| __| __| __| __| __| 4 | __| __| | __| __| __| __| __| __| | __| __| __| __| __| __| __|

___ See continuation sheet

Verbal Boundary Description

(Describe the boundaries of the property on a continuation sheet.)

Boundary Justification

(Explain why the boundaries were selected on a continuation sheet.)

11. Form Prepared By

name/title____________________________________________________________________________________________

organization________________________________________________________________ date______________________

street & number_________________________________________________________ telephone____________________

city or town______________________________________________ state___________________ zip code _____________

Additional Documentation

Submit the following items with the completed form:

Continuation Sheets

Maps

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

A sketch map for historic districts and properties having large acreage or numerous resources.

Photographs

Representative black and white photographs of the property.

Additional items

(Check with the SHPO or FPO for any additional items)

Property Owner

(Complete this item at the request of the SHPO or FPO.)

name ______________________________________________________________________________________________

street & number________________________________________________________ telephone____________________

city or town_______________________________________________ state__________________ zip code _____________

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. 470 et seq.).

Estimated Burden Statement: Public reporting burden for this form is estimated to average 18.1 hours per response including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding this burden estimate or any aspect of this form to the Chief, Administrative Services Division, National Park Service, P.0. Box 37127, Washington, DC 20013-7127; and the Office of Management and Budget, Paperwork Reductions Project (1024-0018), Washington, DC 20503.

NPS Form 10-900-a OMB No. 1024-0018

(8-86)

United States Department of the Interior

National Park Service

National Register of Historic Places

CONTINUATION SHEET

Section _____ Page _____ ______________________________

name of property

______________________________

county and State

NPS Form 10-900-a OMB No. 1024-0018

(8-86)

United States Department of the Interior

National Park Service

National Register of Historic Places

CONTINUATION SHEET

Section ______ Page ______ ______________________________

name of property

______________________________

county and State

______________________________

name of multiple property listing

Send inquiries about this page to kathleen.schamel2@va.gov.