"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

Commercial

Other

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

___________

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

Commercial

Other

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

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

Additions

If yes, describe

Yes

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#______________________________