Nomination form.pdff,IN
1 1 1..,
Edmonds Register of
Historic Historic
Preservation
Commission Nomination For]
Type or print all entries – Please complete all applicable sections.
FOR OFFICE USE
ONLY
Date Received: , 1 i
Received by:.1.
File #: ("t A 1.,( I C -
Survey/Site #: (41"
Historic Name (if applicable):
Common (or Current) Name (if applicable):
Street Address or Location Description:
&l&
City / ZIP Code; '! j /Parcel Number: _ 0-3 ��1
City/ State /ZIP Code:/E.,, A �` �" Phone �. �..
#
Name (say "Owner" if same as owner listed above):
Contact Address: Street:
��4�- City /ZIP:
��,
Contact Phone #:
Date Form Completed:
I / WE the undersigned certify that we are the owners of the property identified on this forin and hereby give our
consent to having the property li ed on the Edmonds Register of Historic Plces.
w�Name (Pleas rm , '• ,-..._, ,; 1 �,�"�.. `�..
Signatur�
Name (Pie e Print)
Signature
Date 11z-&11 11 2—
Date 4" .m ` `° ..
Edmonds Register of Historic Places Nomination Form Page 1
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:9 Architect:
Builder or Engineer (
Architectural Styles)*: E Building f
Roof Type*: "Cladding*
* Note: See later reference sheets for list of choices for these items.
r + i
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Overall
Changes from
Condition:
Original:
Excellent
Plan:
Cladding:
Windows:
Other: Site:
Good
Intact
Intact
Intact
Intact 140riginal Site
Fair
Slight
Slight
Slight
Slight
Moved
Deteriorated
Moderate
Moderate
Moderate
Moderate
Date Moved:
Ruins
Extensive
Extensive
Extensive
Extensive
Unexposed
Unknown
Unknown
Unknown
Unknown
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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
_BrickA
Concrete poured
_ A. Comp - shingle
Other
_ Cross/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 d
_Stone
Metal - corrugated
_ Wood shingle
None
_ U -Shape
Other
_Unknown
_ Metal - standing seam
_ Octagonal
Y -Shape
G�—Post
Plank
Other
& Beam
Steel
Stone - cut
Number of Stories Stone - uncut
Unknown
Edmonds Register of Historic Places Nomination Form Page 3