HISTORIC RESOURCES SURVEY FORM
HISTORIC PROPERTY NAME
COMMON/CURRENT PROPERTY NAME
PROPERTY ADDRESS
ASSESSOR’S PARCEL NUMBER
OWNER/OCCUPANT
OWNER’S ADDRESS
DIGITAL PHOTOGRAPH
(To be submitted separately)
PROPERTY’S HISTORIC USE
PROPERTY’S CURRENT USE
ARCHITECT’S NAME
BUILDER/CONTRACTOR
DATE OF CONSTRUCTION
ARCHITECTURAL STYLE OR VERNACULAR BLDG TYPE
PHOTO BY
DATE
FORM PREPARED BY
VIEW OF PHOTO (DIRECTION)
DATE
PROPERTY DESCRIPTION (GEOGRAPHICAL DATA: LOT SHAPE, LOT DIMENSIONS)
Form Designed by Graham C. Garfield
History of Structure
CHAIN OF OWNERSHIP OR OCCUPATION (Attach additional pages, if necessary)
PREVIOUS OWNERS
DATE(S) OF OWNERSHIP
USE
CURRENT DESIGNATIONS
Is property National Register listed?
YES
NO
If yes, is it a ….
Individual property
District
If no, it is ….
Not Eligible
Eligible
Is property an Urbana local landmark?
YES
NO
STATEMENT OF HISTORIC SIGNIFICANCE
INFORMATION SOURCES
Structure Survey
INTEGRITY
CONDITION
Unaltered (All or most architectural details present)
Slight modifications (Largely intact, but lacking some details)
Major alterations (All or most architectural details missing)
Excellent (Roof, walls and foundation in good repair)
Good (Same as “Excellent,” but in need of some maintenance work)
Poor (Major overhaul work required)
ADDITIONS/ALTERATIONS (Include dates and architects/contractors, if known)
CURRENT AND HISTORIC USES
Current Historic
Single-Family Residence
Multi-Family Residence
Apartment Building
Commercial
Industrial
Public Building
Educational Building
Religious Building
Vacant
Other
EXTERIOR WALL MATERIAL
ORNAMENTAL/ARCHITECTURAL DETAILS
(Check all that apply)
Porte-Cochere
Arcading
Cornice
Pilasters
Cornice returns
Recessed panels
Porch
Buttresses
Stoop
Piers
Balcony
Spandrels
Oriel window
Portico
Columns or Posts
Quoins
Tower or Turret
Bay windows
Other
ROOF FEATURES
ROOF MATERIAL
Asphalt shingles
Wood shingles
Slate shingles
Tile shingles
Metal
Tar
Other
Brick
Stone
Wood siding
Wood shingles
Stucco (historic or modern)
Asphalt siding
Asbestos siding
Concrete block
Artificial siding
Other
ROOF TYPE
Hip
Flat
Mansard
Gable
Shed
Hipped Gable
Pyramidal
Other
Dormer
Urn/Finial
Bargeboard
Belvedere
Gablet
Parapet
Skylight
Other
DESCRIBE ABOVE ORNAMENTAL DETAILS
OUTBUILDINGS
Garage
Carport
Coach House
Pool
Describe location, construction, and date of detached structures:
ADDITIONAL COMMENTS/FEATURES
Gazebo
Greenhouse
Storage Shed
Other