Kentucky Historic Properties Survey Form

KENTUCKY HISTORIC PROPERTIES / COUNTY: ______
SURVEY FORM 2017-1 / RESOURCE NUMBER: ______
EVALUATION: ______
CONDITION: ______

1. NAME OF RESOURCE:

How Determined: ______

1. ADDRESS/LOCATION:

OWNER CONTACT (if known):

1. GEOGRAPHIC DATA:

Quad: / Date:
Lat: / Long:

1. FIELD RECORDER/AFFILIATION:

1. DATE RECORDED:

1. SPONSOR/INITIATION: ______

Sponsor Name:

1. PREVIOUSLY RECORDED: ______

1. REPORT/NR REFERENCE:

1. ORIGINAL PRIMARY FUNCTION:

______

1. CURRENT PRIMARY FUNCTION:

______

1. ORIGINAL CONSTRUCTION DATE:

Estimated: ______
Documented:

1. MAJOR ADDITIONS/MODIFICATION (specify)::

______

1. MODIFICATION ASSESSMENT:
______

1. CONSTRUCTION METHOD AND MATERIAL:

Original/Primary (if known): ______
Subsequent/Secondary (if known): ______
Other:

1. EXTERIOR WALL CLADDING:

Original (if known): ______
Current: ______

1. DIMENSIONS:

Height: ______Acreage:

1. ARCHITECTURAL FORM/SHAPE: ______

1. ARCHITECTURAL TYPE (choose from applicable list(s)):

Type: ______
Other: ______

1. ARCHITECTURAL STYLE (choose from applicable list(s)):

Style: ______
Other: ______

1. FOUNDATION WALLS:

Type: ______
Material: ______

1. ROOFING

Configuration: ______
Roof Covering: ______

1. ARCHITECT/BUILDER (if known):

1. WINDOWS: Original Replacement

Current Material: ______
Sash Operation: ______
Glazing Pattern: ______

1. NUMBER OF SUPPORT RESOURCES: ______

(If yes, complete #27 and #28 below)

1. COMMENTS/HISTORICAL INFORMATION (Complete on Continuation Sheet)

1. PHOTO (Place Additional Photos below under 26 cont’d)

SHPO Review Date / SHPO Data Entry Date
COUNTY: ______/ KENTUCKY HISTORIC PROPERTIES SURVEY
RESOURCE NUMBER: ______/ CONTINUATION SHEET (2017-1)
PAGE 1

1. SUPPORT RESOURCES:

SITE PLAN KEY / NAME OF RESOURCE / FUNCTION / CONSTRUCTION DATE / METHOD/MATERIAL
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______
______/ ______/ ______

1. SITE PLAN (Complete if #24 was answered or if you are using sub-numbers):

Kentucky Heritage Council * Frankfort, KY 40601 * (502) 564-7005

COUNTY: ______/ KENTUCKY HISTORIC PROPERTIES SURVEY
RESOURCE NUMBER: ______/ CONTINUATION SHEET (2017-1)
PAGE 1

Kentucky Heritage Council * Frankfort, KY 40601 * (502) 564-7005

COUNTY: ______/ KENTUCKY HISTORIC PROPERTIES SURVEY
RESOURCE NUMBER: ______/ CONTINUATION SHEET (2017-1)
PAGE 1

Kentucky Heritage Council * Frankfort, KY 40601 * (502) 564-7005

COUNTY: ______/ KENTUCKY HISTORIC PROPERTIES SURVEY
RESOURCE NUMBER: ______/ CONTINUATION SHEET (2017-1)
PAGE 1

1. 
   MAP (Scan or attach copy of map showing exact location of resources):

Kentucky Heritage Council * Frankfort, KY 40601 * (502) 564-7005

COUNTY: ______/ KENTUCKY HISTORIC PROPERTIES SURVEY
RESOURCE NUMBER: ______/ CONTINUATION SHEET (2017-1)
PAGE 1

25. (continued) COMMENTS/HISTORICAL INFORMATION:

1. (continued) ADDITIONAL IMAGES:

Caption:

Caption:

Kentucky Heritage Council * Frankfort, KY 40601 * (502) 564-7005