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Please read the instructions for completing this form carefully. Inadequate, incomplete, or inaccurate information will result in delays in this form's review.
1. Society's Site Number: 32
2. Applicant's name, address, phone, fax, and email: ________________________
________________________________________________________________________
________________________________________________________________________
3. Street Address and Township-Range-Section of Historic Building:
________________________________________________________________________
4. Construction Date and Alteration Dates: __________________________________
________________________________________________________________________
5. First Owner of Historic Building: _________________________________________
6. Architect's Name: ______________________________________________________
7. Description of Associations between the property and person or events of historic significance. List references (local historians, centennial books, etc.):
________________________________________________________________________
________________________________________________________________________
8. Additional information relevant to the eligibility evaluation:
________________________________________________________________________
________________________________________________________________________
9. Description of Rehabilitation Plans:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
10. Applying for Federal Preservation Tax Credit? _______ yes _______ no
11. Have you read the Secretary of the Interior's Standards for Rehabilitation? _______ yes _______ no
12. Attached Photographs (clear 35mm photographs, no photocopies). _____(check)
13. Attached City and USGS Topographic Maps with building location and Renaissance Zone boundary marked. _____(check)
14. List other attachments: _________________________________________________
15. Send to:
Archeology and Historic Preservation Division
State Historical Society of North Dakota
North Dakota Heritage Center
612 E. Boulevard
Bismarck, ND 58505-0830
For SHSND Use Only SHSND Date Stamp
[ ]Additional information requested:
date______________________ initials____________
date______________________ initials____________
date______________________ initials____________
[ ]Complete Evaluation Form and materials received:
date______________________ initials____________
[ ]Verification letter to Division of Community Services sent:
date______________________ initials____________
[ ]New site number assigned:
date______________________ initials____________
[ ] Preliminary project concerns regarding conformance with Secretary’s Standards: