Nomination form.pdff,1% Edmonds
Edmonds Register of
Historic Historic Places
Preservation
Commission Nomination Form
Type or print all entries — Please coiiiplete all applicable sections.
FOR OFFICIAL USE ONLY
Date Received:
Received by: C$
File #:
Survey/Site M
Historic Name (if applicable): l °(,.„�' i� ` i �.... ��. ,t.,^
Common (or Current) Name (if applicable) 1211" , `.1 ° t' ' i .�, y � r ,a,t L CA',< ,"�C .. :.�.
Site Address / Location
Sheet Address or Location Description:
w 1 g4 4 N kcuo "A'-,
'-
C Y t .,..4 �gym a Tax / Parcel Number:
City /ZIP Code ��
Name:
Street Address:
City / State / ZIP Code:
Phone #:
Name (say "Owner" if same as owner listed above):
Contact Address: Street: City / ZIP:
Contact Phone #:
Date Form Completed:
I / WE the undersigned certify that we are the owners of the property identified on this form and hereby give our
consent to having the property listed on the Edmonds Register of Historic Places.
Name (Please Print)
Signature
Name (Please Print)
Signature
Date
Date
Edmonds Register of Historic Places Nomination Form Page l
%`Eli' iblty for Listing on the Edmonds Register`
Site is listed on the National Register of Historic Places (if checked, skip to Section F)
Site is listed on the State Register of Historic Places (If checked, skip to Section F)
Historical Significance — Please check all that apply:
1. Is associated with events that have made a significant contribution to the broad patterns of national, state or local
history.
2.� Embodies the distinctive architectural characteristics of a type, period, style or method of design or construction, or
represents a significant and distinguishable entity whose components may lack individual distinction.
3. Is an outstanding work of a designer, builder or architect who has made a substantial contribution to the art.
4. vl' Exemplifies or reflects special elements of the city's cultural, special, economic, political, aesthetic, engineering or
architectural history.
5. �a�� Is associated with the lives of persons significant in national, state or local history.
6. Has yielded or may be likely to yield important archaeological information related to history or prehistory.
7. 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 a historic person or event.
S. Is a birthplace or grave of a historical figure of outstanding importance and is the only surviving structure or site
associated with that person.
9. Is a cemetery which derives its primary significance from age, from distinctive design features, or from association
with historic events or cultural patterns.
10. Is a reconstructed building that has been executed in a historically accurate marmer on the original site.
11. Is a creative and unique example of folk architecture and design created by persons not formally trained in the
architectural or design professions, and which does not fit into formal architectural or historical categories; the
designation shall include description of the boundaries.
Historical Description
In the space below, describe the history and significance of the site to Edmonds' heritage. You may elect to
describe the site's significance in your own words, attach copies of other documents or photographs, and/or make
reference to other materials (noting where those materials are available to be reviewed). For example, you may
simply note that the site is on an historical survey, noting the survey name and site number. (Please feel free to
attach any additional continuation sheets if you need more space,)
Edmonds Register ofHistoric Places Nomination Form Page 2
This section must be completed if the site is not on the State or National Register, or it is not on an approved historic survey.
Please provide as much information as you can.
Year Built: t f 2• Architect:
Builder or Engineer (specify):
Architectural Style(s)*.'t.tt='wfl:4ce�i Building Form*:
Roof Type*:Cladding
* Note: See later reference sheets for list of choices for these items.
------------------------------------------------------------------------------------------------------------------------------------
Overall
Changes from
Condition:
Original:
Excellent
Plan:
Cladding:
Windows: Other:
Site:
Good
Intact
Intact
Intact
Intact
Original Site
Fair
Slight
Slight
Slight
Slight
Moved
Deteriorated
a"� Moderate
Moderate
Moderate
Moderate
Date Moved:
Ruins
Extensive
Extensive
Extensive
Extensive
Unexposed
Unknown
Unknown
Unknown
Unknown
------------------------------------------------------------------------------------------------------------------------------------
Plan Type:
Structural System:
Foundation:
Roof Material:
Apsidal
Pavilion
_Balloon/Platform
Brick
"Asphalt Comp
Metal --Tile
Center Space/
Polygonal
Braced Frame
Concrete block
A. Comp - built up
None
Courtyard
Rectangle
Brick
_Concrete poured
A. Comp - shingle
Other
Gross/Cruciform
_ Round
Clay Tile
_Log
A. Comp — rolled
Slate
E -Shape
Semi -circular
Concrete block
_None
Tile
Unknown
_ Hexagonal
Square
—Concrete poured
_Other
Tile - clay
Wood
H -Shape
Triangular
Log
Parged
Tile - concrete
Wood plank
Irregular
T -Shape
Mixed
_Post & Pier
Metal
Wood shake
L -Shape
Unknown
_None
_Stone
Metal - corrugated
Wood shingle
None
U -Shape
_Other
_Unknown
Metal - standing seam
Octagonal
Y -Shape
Plank
Other
Post & Beam
Steel
Stone - cut
Number of Stories
Stone - uncut
Unknown
Edmonds Register of Historic Places Nomination Form Page 3
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Describe the present and original (if known) physical appearance:
(Use coiahniatimi sheets if necessary, and for any photographs or copies you areproviding.)
64,
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(Please list atid reference cm), sources which help docitinent the historical value of the, site.)
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Location Detail
A)
Parcel # C
UTM Reference: Zone Eastingi0 LA e,') Northing lc -t
Township Range 2? Section 'A Section �-AiiV 1/4 1/4 Section
Category
District
T Building(s)
Structure
Site
Object
Within a District?
Yes
No
Ownership
Public
Private
Both
Contributing?
Yes
Resource Status
Survey/Inventory
National Register
National Landmark
State Register
Determined Eligible
Other:
No
Unknown
Local District:
Usage
Current:
Historic:
National or State Register / District:
Edmonds Register of Historic Places Nomination Form Page 4
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Location Detail
A)
Parcel # C
UTM Reference: Zone Eastingi0 LA e,') Northing lc -t
Township Range 2? Section 'A Section �-AiiV 1/4 1/4 Section
Category
District
T Building(s)
Structure
Site
Object
Within a District?
Yes
No
Ownership
Public
Private
Both
Contributing?
Yes
Resource Status
Survey/Inventory
National Register
National Landmark
State Register
Determined Eligible
Other:
No
Unknown
Local District:
Usage
Current:
Historic:
National or State Register / District:
Edmonds Register of Historic Places Nomination Form Page 4