PAGE 2        PRELIMINARY PROPERTY EVALUATION FORM                           Blair Historic Properties Registry

ARCHITECTURAL DESCRIPTION (remember to provide photographs of the building with this form):



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CONSTRUCTION HISTORY (include description and dates of major additions, alterations, or demolitions):



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HISTORICAL BACKGROUND (discuss important persons and events associated with this building):





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INFORMATION SOURCES (be specific):



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SIGNIFICANCE (check appropriate categories) Architectural significance: Historical significance:
[ ] represents the work of a master [ ] associated with significant person(s)
[ ] possess high artistic value [ ] associated with significant event
[ ] represents a type, period, [ ] associated with a pattern of events
or method of construction [ ] contributes to a historic district

STATEMENT OF SIGNIFICANCE (briefly justify the significance checked above):

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FORM COMPLETED BY
NAME:

ADDRESS:

PHONE: DATE:

Email Address: