Form 780-2125 "Architectural/Historic Inventory Form" - Missouri

What Is Form 780-2125?

This is a legal form that was released by the Missouri Department of Natural Resources - a government authority operating within Missouri. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2012;
  • The latest edition provided by the Missouri Department of Natural Resources;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 780-2125 by clicking the link below or browse more documents and templates provided by the Missouri Department of Natural Resources.

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Download Form 780-2125 "Architectural/Historic Inventory Form" - Missouri

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MISSOURI DEPARTMENT OF NATURAL RESOURCES
STATE HISTORIC PRESERVATION OFFICE, P.O. Box 176, Jefferson City, MO 65102
ARCHITECTURAL/HISTORIC INVENTORY FORM
1. SURVEY NO.
2. SURVEY NAME:
3. COUNTY:
4. ADDRESS (STREET NO.)
STREET (NAME)
5. CITY:
VICINITY:
6. UTM:
OR
LAT:
7. TOWNSHIP/RANGE/SECTION:
/
/
T:
R:
S:
LONG:
8. HISTORIC NAME (IF KNOWN):
9. PRESENT/OTHER NAME (IF KNOWN):
10. OWNERSHIP:
11A. HISTORIC USE (IF KNOWN):
11B. CURRENT USE:
PRIVATE
PUBLIC
HISTORICAL INFORMATION
12. CONSTRUCTION DATE:
15. ARCHITECT:
18. PREVIOUSLY SURVEYED?
CITE SURVEY NAME IN BOX 22 CONT.
(PAGE 3)
13. SIGNIFICANT DATE/PERIOD:
16. BUILDER/CONTRACTOR:
19. ON NATIONAL REGISTER?
INDIVIDUAL
DISTRICT
CITE NOMINATION NAME IN BOX 22 CONT.
(PAGE 3)
14. AREA(S) OF SIGNIFICANCE:
17. ORIGINAL OR SIGNIFICANT OWNER:
20. NATIONAL REGISTER ELIGIBLE?
INDIVIDUALLY ELIGIBLE
DISTRICT POTENTIAL (
C
NC )
NOT ELIGIBLE
NOT DETERMINED
.
.
21. HISTORY AND SIGNIFICANCE ON CONTINUATION PAGE
22. SOURCES OF INFORMATION ON CONTINUATION PAGE
ARCHITECTURAL INFORMATION
23. CATEGORY OF PROPERTY:
30: ROOF MATERIAL:
37.WINDOWS:
_____________________
BUILDING(S)
SITE
STRUCTURE
HISTORIC
OBJECT
REPLACEMENT
PANE ARRANGEMENT:
24. VERNACULAR OR PROPERTY TYPE:
31. CHIMNEY PLACEMENT:
ACREAGE (RURAL):
38.
VISIBLE FROM PUBLIC ROAD?
25. ARCHITECTURAL STYLE:
32. STRUCTURAL SYSTEM:
39. CHANGES (DESCRIBE IN BOX 41 CONT.):
ADDITION(S) DATE(S):
ALTERED
DATE(S):
MOVED
DATE(S):
26. PLAN SHAPE:
33. EXTERIOR WALL CLADDING:
OTHER
DATE(S):
ENDANGERED BY:
27. NO. OF STORIES:
34. FOUNDATION MATERIAL:
ST
28.NO. OF BAYS (1
FLOOR):
35. BASEMENT TYPE:
40. NO. OF OUTBUILDINGS (DESCRIBE IN BOX 40 CONT.):
29. ROOF TYPE:
36. FRONT PORCH TYPE/PLACEMENT:
41. FURTHER DESCRIPTION OF BUILDING FEATURES
AND ASSOCIATED RESOURCES ON CONTINUATION
PAGE.
OTHER
42. CURRENT OWNER/ADDRESS:
43. FORM PREPARED BY (NAME AND ORG.):
44. SURVEY DATE:
45. DATE OF REVISIONS:
FOR SHPO USE
DATE ENTERED IN INVENTORY:
LEVEL OF SURVEY
ADDITIONAL RESEARCH NEEDED?
RECONNAISSANCE
INTENSIVE
YES
NO
NATIONAL REGISTER STATUS:
OTHER:
LISTED
IN LISTED DISTRICT
NAME:
PENDING LISTING
ELIGIBLE (INDIVIDUALLY)
ELIGIBLE (DISTRICT)
NOT ELIGIBLE
NOT DETERMINED
780-2125 (09-12)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
STATE HISTORIC PRESERVATION OFFICE, P.O. Box 176, Jefferson City, MO 65102
ARCHITECTURAL/HISTORIC INVENTORY FORM
1. SURVEY NO.
2. SURVEY NAME:
3. COUNTY:
4. ADDRESS (STREET NO.)
STREET (NAME)
5. CITY:
VICINITY:
6. UTM:
OR
LAT:
7. TOWNSHIP/RANGE/SECTION:
/
/
T:
R:
S:
LONG:
8. HISTORIC NAME (IF KNOWN):
9. PRESENT/OTHER NAME (IF KNOWN):
10. OWNERSHIP:
11A. HISTORIC USE (IF KNOWN):
11B. CURRENT USE:
PRIVATE
PUBLIC
HISTORICAL INFORMATION
12. CONSTRUCTION DATE:
15. ARCHITECT:
18. PREVIOUSLY SURVEYED?
CITE SURVEY NAME IN BOX 22 CONT.
(PAGE 3)
13. SIGNIFICANT DATE/PERIOD:
16. BUILDER/CONTRACTOR:
19. ON NATIONAL REGISTER?
INDIVIDUAL
DISTRICT
CITE NOMINATION NAME IN BOX 22 CONT.
(PAGE 3)
14. AREA(S) OF SIGNIFICANCE:
17. ORIGINAL OR SIGNIFICANT OWNER:
20. NATIONAL REGISTER ELIGIBLE?
INDIVIDUALLY ELIGIBLE
DISTRICT POTENTIAL (
C
NC )
NOT ELIGIBLE
NOT DETERMINED
.
.
21. HISTORY AND SIGNIFICANCE ON CONTINUATION PAGE
22. SOURCES OF INFORMATION ON CONTINUATION PAGE
ARCHITECTURAL INFORMATION
23. CATEGORY OF PROPERTY:
30: ROOF MATERIAL:
37.WINDOWS:
_____________________
BUILDING(S)
SITE
STRUCTURE
HISTORIC
OBJECT
REPLACEMENT
PANE ARRANGEMENT:
24. VERNACULAR OR PROPERTY TYPE:
31. CHIMNEY PLACEMENT:
ACREAGE (RURAL):
38.
VISIBLE FROM PUBLIC ROAD?
25. ARCHITECTURAL STYLE:
32. STRUCTURAL SYSTEM:
39. CHANGES (DESCRIBE IN BOX 41 CONT.):
ADDITION(S) DATE(S):
ALTERED
DATE(S):
MOVED
DATE(S):
26. PLAN SHAPE:
33. EXTERIOR WALL CLADDING:
OTHER
DATE(S):
ENDANGERED BY:
27. NO. OF STORIES:
34. FOUNDATION MATERIAL:
ST
28.NO. OF BAYS (1
FLOOR):
35. BASEMENT TYPE:
40. NO. OF OUTBUILDINGS (DESCRIBE IN BOX 40 CONT.):
29. ROOF TYPE:
36. FRONT PORCH TYPE/PLACEMENT:
41. FURTHER DESCRIPTION OF BUILDING FEATURES
AND ASSOCIATED RESOURCES ON CONTINUATION
PAGE.
OTHER
42. CURRENT OWNER/ADDRESS:
43. FORM PREPARED BY (NAME AND ORG.):
44. SURVEY DATE:
45. DATE OF REVISIONS:
FOR SHPO USE
DATE ENTERED IN INVENTORY:
LEVEL OF SURVEY
ADDITIONAL RESEARCH NEEDED?
RECONNAISSANCE
INTENSIVE
YES
NO
NATIONAL REGISTER STATUS:
OTHER:
LISTED
IN LISTED DISTRICT
NAME:
PENDING LISTING
ELIGIBLE (INDIVIDUALLY)
ELIGIBLE (DISTRICT)
NOT ELIGIBLE
NOT DETERMINED
780-2125 (09-12)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
STATE HISTORIC PRESERVATION OFFICE, P.O. Box 176, Jefferson City, MO 65102
ARCHITECTURAL/HISTORIC INVENTORY FORM
LOCATION MAP (include north arrow)
SITE MAP/PLAN (include north arrow)
PHOTOGRAPH
PHOTOGRAPHER:
DATE:
DESCRIPTION:
INSERT PHOTOGRAPH OF PRIMARY STRUCTURE ON PROPERTY.
780-2125 (09-12)
MISSOURI DEPARTMENT OF NATURAL RESOURCES
STATE HISTORIC PRESERVATION OFFICE, P.O. Box 176, Jefferson City, MO 65102
ARCHITECTURAL/HISTORIC INVENTORY FORM
ADDITIONAL INFORMATION
21. (CONT.) HISTORY AND SIGNIFICANCE. EXPAND BOX AS NECESSARY, OR ADD CONTINUATION PAGES.
22. (CONT.) SOURCES OF INFORMATION. EXPAND BOX AS NECESSARY, OR ADD CONTINUATION PAGES.
40. (CONT.) DESCRIPTION OF ENVIRONMENT AND OUTBUILDINGS. EXPAND BOX AS NECESSARY, OR ADD CONTINUATION PAGES.
41. (CONT.) DESCRIPTION OF PRIMARY RESOURCE. EXPAND BOX AS NECESSARY, OR ADD CONTINUATION PAGES.
780-2125 (09-12)
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