Historic Property Inventory Form - West Virginia Division of Culture and History - West Virginia
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Internal Rating:
WEST VIRGINIA HISTORIC PROPERTY
INVENTORY FORM
Street Address
Common/Historic Name/Both
Field Survey #
Site # (SHPO Only)
Town or Community
County
Negative No.
NR Listed Date
Architect/Builder
Date of Construction
Style
Exterior Siding/Materials
Roofing Material
Foundation
Property Use or Function
UTM#
Residence
O
Commercial
O
Other
O
Photograph
Survey Organization & Date
Quadrangle Name
(2” x 3” Contact)
Part of What Survey/FR#
Sketch Map of Property
Or Attach Copy of USGS Map
N
___________
Internal Rating:
WEST VIRGINIA HISTORIC PROPERTY
INVENTORY FORM
Street Address
Common/Historic Name/Both
Field Survey #
Site # (SHPO Only)
Town or Community
County
Negative No.
NR Listed Date
Architect/Builder
Date of Construction
Style
Exterior Siding/Materials
Roofing Material
Foundation
Property Use or Function
UTM#
Residence
O
Commercial
O
Other
O
Photograph
Survey Organization & Date
Quadrangle Name
(2” x 3” Contact)
Part of What Survey/FR#
Sketch Map of Property
Or Attach Copy of USGS Map
N
Present Owners
Owners Mailing Address
Phone #
Describe Setting
_____________ Acres
_____ Archaeological
Artifacts Present
Description of Building or Site (Original and Present)
__________Stories
_________Front Bays
(Use Continuation Sheets)
Alterations
If yes, describe
Yes
No
Additions
If yes, describe
Yes
No
Describe All Outbuildings
(Use Continuation Sheets)
Statement of Significance
(Use Continuation Sheets)
Bibliographical References
(Use Continuation Sheets)
Form Prepared By:
Date:
Name/Organization:
Address:
Phone #:
This program receives federal funds from the National Park Service. Regulations of the U. S. Department of the Interior prohibit unlawful discrimination in department Federally Assisted
Programs on the basis of race, color, national origin, age or handicap. Any person who believes he or she has been discriminated against in any program, activity, or facility operated by a
recipient of Federal Assistance should write to: Director, Equal Opportunity Program, U.S. Department of the Interior, National Park Service, P.O. Box 37127, Washington, D.C. 20013-7127.
WEST VIRGINIA HISTORIC PROPERTY FORM
CONTINUATION SHEET
NAME___________________________________
SITE#______________________________
