Nomination form.pdff,1% Edmonds
Edmonds Register of
Historic Historic Places
Preservation
Commission Domination Form
Type or print all entries — Please complete all applicable sections.
Historic Name if applicable):
Common (or Current) Name (if applicable):
Site Address / Location
.mm
Street Address or Location Description:
FOR OFFICIAL USE ONLY
Date Received:w
Received by:,,',`
File #: ew„m ” ,.(,.,, 4',. w .,-
Survey/Site #: i -
. � ��`��Cit /ZIPCode Tax / Parcel Number
m
i,
Name:
Street Address:
City/ State/ ZIP Code 16CUi Phone #:
Name (say "Owner" if same as owner listed above):
Contact Address: Street:
Contact Phone #:
Date Form Completed:
City / ZIP:
4/
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 Porro Page l
V 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. � �&nbodies 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. , ZL Exemplifies or reflects special elements of the city's cultural, special, economic, political, aesthetic, engineering or
architectural history.
5. 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.
8. 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 manner 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 of Historic Places Nomination Form Page 2
�Ph, stca���Descwipton
7 nis section Must 07 completea ij Me site is 7157 on 7717 . , 7,75715557 .,.
Please Provide as much inf6rination as you cam
Year Built: 6 Architect:
Builder or Engineer (specify):
Architectural Style(s)*: `t ;, mf,� i`.d Building Form*:
Roof Type*: f : "�,A41A, t , F ij, t 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 V/
_ Original Site
Fair
Slight
Slight
Slight
Slight
Moved
Deteriorated
Moderate
Moderate
V Moderate
Moderate
Date Moved:
Ruins
Extensive
Extensive
Extensive
Extensive
Unexposed
Unknown
Unknown
Unknown
V 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
T Octagonal
Other
r„p
f m• Number of Stories
U -Shape Other
Y -Shape Plank
Post & Beam
Steel
Stone - cut
Stone - uncut
_ Unknown
"Unknown Metal - standing seam
Edmonds Register of Historic Places Nomination Form Page 3
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Describe the present and original (if known) physical appearance:
(Use continuation sheets if necessary, and.lbr any photographs or copies you are providing)
(Please list and reference any sources vvhich help document the historical value of'the site.)
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RVW
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Location Detail
Parcel #
UTM Reference:
Township
Category
District
Building(s)
Structure
Site
Object
Within a District?
Yes
No
Zone Easting Northing
Range Section 'A Section 1/4 1/4 Section
Ownership Resource Status Usage
Public Survey/Inventory Current:
ITPrivate National Register o
Both National Landmark
State Register Historic:
Determined Eligible
Other:
Contributing? Local District:
Yes National or State Register / District:
No
_L -Unknown
Edmonds Register of Historic Places Nomination Foriii Page 4