Douglas CountyRegister of Landmark Properties

Nomination Form

Historic Name: ______

REGISTER OF LANDMARK PROPERTIES

NOMINATION FORM

Official Use Only

File Number:
Date Received:
  1. Name of Property

Historic Name(s):

Source:

Current Name:

  1. Address of Property (Provide the address for all properties included in the nomination)

Street Address:

City:County: Zip:

  1. Geographical Data
  2. Legal Description of Property

1/4 of 1/4 of 1/4 of 1/4 of Section

Township Range Lot(s) Block Addition

Total Acres being landmarked:

If the legal description is by metes and bounds, attach a copy of the most recent vesting deed with legal attached.

If a survey has been done on the property, please include a copy for reference purposes.

  1. Boundary Description:
  1. Boundary Justification:
  1. Present Owner(s) of Property

Name:

Address:Phone:

City:State: Zip:

(If multiple ownership, please list names and addresses of each owner.)

5. Preparer(s) of Nomination

(Provide information below for each preparer.)

Name: Date:

Address: Phone:

City:State: Zip:

Representing (optional):

6. Classification of Property

Category(s) of Property: building structure site

object district other:

Property Ownership: private public-local public-state(Check as many boxes as apply)

public-federal

Number of Resources

ContributingNoncontributing

Building ______

Structure ______

Site ______

Object ______

Total ______

  1. Other Landmark Designations

Has the property, or portions thereof, received any other landmark designations?

no if yes individual in district

Date designated:

If only a portion was previously designated, please describe:

Designated by (Name of municipality, county, state, or federal agency):

Designation Number:

  1. Condition of Property

(Please describe each structure/resource below.)

Excellent Good Fair Deteriorated Ruins

9.Locational Status of Buildings, Structures, or Objects

Original Location Moved,Date of Move:

Source of Information:

  1. Use of Property (See Appendix A of Landmark Nomination Instructions for more detail)

Historic:

Current:

  1. Original Owner:

Source of Information:

  1. Year(s) of Construction:

Give the range of dates beginning with the earliest construction and ending with the majority of construction within the district.

Source of Information:

  1. Architect, Builder, Engineer, Artist, or Designer:

Source of Information:

  1. Architectural Style/Engineering Type:
  1. Description of the Property

Describe the current condition and pre-historic and/or historic appearance (if known) of the land and any structures.

  1. Alterations to the Property

Describe and date significant changes made to the building(s), construction(s), and/or land.

Source of Information:

  1. Significance of the Property
  1. Nomination Criteria: Property, structure, or resource is at least fifty years old. (Check applicable criteria. See Landmark Nomination Instructions for complete criteria language.)

Property is associated with events that have made a significant contribution to history

Property is connected with person(s) significant in history

Property has distinctive characteristics of a type, period, method of construction, or artisan

Property is of geographic importance

Property contains the possibility of important discoveries related to prehistory or history

  1. Areas of Significance:

(See Appendix B of Landmark Nomination Instructionsfor more detail. Check as many as appropriate.)

Select one or more areas of significance for the property from the list below. Areas of significance must be justified in the Statement of Significance (#18).

Agricultural / Health & Medicine
Architecture / Industry
Archaeology- prehistoric and historic / Invention
Art / Landscape Architecture
Commerce / Law
Communications / Literature
Community Planning & Development / Military
Conservation / Performing Arts
Economics / Politics & Government
Education / Religion
Engineering / Science
Entertainment & Recreation / Social History
Ethnic Heritage / Transportation
Exploration & Settlement / Other
Geography or Community Identity
  1. Significance Statement

Explain selections from Item # 17 A and B.

Source of information:

  1. Plaque Name

Recommended name and date to be placed on plaque:

20. OWNER CONSENT FORM

Each partial owner must sign a separate form. Reproduce form as needed. All signatures must be notarized.

I,

(type or print name)

(title)

certify that I am the sole owner /partial owner of the land and property located at

street number street name

city county

and that I hereby give my written consent and approval for this property’s nomination to and inclusion in theDouglas County Register of Landmark Properties.

______

signature

State of Colorado)

)ss

County of ______)

Subscribed and sworn to before me, in my presence, this_____day of ______, 20_____

by ______.

(seal) ______

Notary Public

______

Print Name

My term expires: ______

21. Bibliography

Cite the books, articles, and other sources used in preparing this form. Please use the Chicago Style manual to properly document resources (see Landmark Nomination Instructions for assistance).

  1. Maps

Attach the following maps:

  1. Vicinity Map
  2. U.S.G.S. Quadrangle Map
  3. Sketch Map
  1. Photographs

Attach photographs of the property. Provide a list of the photographs (see Landmark Nomination Instructions for assistance).

  1. Slides or CDs (Optional)

Submit color slides or a CD with digital photos (see Landmark Nomination Instructions for assistance).

25.Additional Nomination Material

Please list below additional information including maps, journal articles, etc. and include page numbers.

26. Amending Douglas CountyLandmark Forms (if applicable)

Please refer to the Douglas County Historic Preservation Landmark designation application instructions for information about amending a landmarked site or district.

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