Utah Office of Preservation
1 IDENTIFICATION
Name of Property:
Address: Twnshp: Range: Section:
City, County: UTM:
Current Owner Name: USGS Map Name & Date:
Current Owner Address:
Tax Number:
Legal Description (include acreage):
2 STATUS/USE
Property Category Evaluation Use
building(s) eligible/contributing Original Use:
structure ineligible/non-contributing
site out-of-period Current Use:
object
3 DOCUMENTATION
Photos: Dates Research Sources (check all sources consulted, whether useful or not)
slides: abstract of title city/county histories
prints: tax card & photo personal interviews
historic: building permit USHS Library
sewer permit USHS Preservation Files
Drawings and Plans Sanborn Maps USHS Architects File
measured floor plans obituary index LDS Family History Library
site sketch map city directories/gazetteers local library:
Historic American Bldg. Survey census records university library(ies):
original plans available at: biographical encyclopedias
other: newspapers
Bibliographical References (books, articles, interviews, etc.)
Attach copies of all research notes, title searches, obituaries, and so forth.
Researcher/Organization: _______________________________________________ Date:___________________
4 ARCHITECTURAL DESCRIPTION
Building Style/Type: No. Stories:
Foundation Material: Wall Material(s):
Additions: none minor major (describe below) Alterations: none minor major (describe below)
Number of associated outbuildings and/or structures .
Briefly describe the principal building, additions or alterations and their dates, and associated outbuildings and structures. Use continuation sheets as necessary.
5 HISTORY
Architect/Builder: Date of Construction:
Historic Themes: Mark themes related to this property with "S" or "C" (S = significant, C = contributing).
(see instructions for details)
Agriculture Economics Industry Politics/
Architecture Education Invention Government
Archeology Engineering Landscape Religion
Art Entertainment/ Architecture Science
Commerce Recreation Law Social History
Communications Ethnic Heritage Literat-ure Transportation
Community Planning Exploration/ Maritime History Other
& Development Settlement Military
Conservation Health/Medicine Performing Arts
Write a chronological history of the property, focusing primarily on the original or principal owners & significant events. Explain and justify any significant themes marked above. Use continuation sheets as necessary.