Town of Concrete Historic Preservation Commission
45672 Main Street/P.O. Box 39
Concrete, WA 98237
360.853.8401
Concrete Historic Landmark/Structure Registration Form
This form is used to nominate properties to the Town of Concrete Register of Historic Places.

Complete each item by entering the requested information.
If you have questions, please ask.
1. Name of Property
Current Name: ________________________________ Historic Name: __________________________
Other Names: _________________________________________________________________________
2. Location
Street Address: _______________________________
Town, State, Zip: Concrete, WA 98237_______
Parcel Number: ________________
3. Classification
Ownership of Property:  Private
 Building(s)
 District

Public-Local
 Site
 Public-State
 Structure
 Public-Federal
Object
4. Owner of Property
Name: ________________________________________ Telephone: _____________________________
Mailing Address: ______________________________________________________________________
Email: _______________________________________________________________________________
5. Form Prepared By:
Name: ________________________________________ Telephone: ____________________________
Organization: ___________________________________ Title: _________________________________
Mailing Address: ______________________________________________________________________
Email: _______________________________________________________________________________
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6. Description of Property
Describe the present and historical physical appearance of the property: (attach additional sheets if necessary)
7. Statement of Significance
Applicable Designation Criteria
(Mark “X” in all the boxes that apply.)











1. It is associated with events that have made a significant contribution to the broad patterns of
national, state or local history.
2. It embodies the distinctive architectural characteristic of a type, period, style or method of
construction, or represents a significant and distinguishable entity whose components may lack
individual distinction.
3. It is an outstanding work of a designer, builder or architect who has made a sustainable
contribution to the art.
4. It exemplifies or reflects special elements of the Town’s cultural, social, economic, political,
aesthetic, engineering or architectural history.
5. It is associated with the lives of persons significant in national, state or local history.
6. It has yielded or is likely to yield important archaeological information.
7. It is a building or structure removed from its original location but which is significant
primarily for architectural value, or which is the only surviving structure significantly
associated with an historic person or event.
8. It is a birthplace or grave of a person of outstanding importance and is the only surviving
structure or site associated with that person.
9. It is a cemetery that derives its primary significance from age, from distinctive design features,
or from association with historic events or cultural patterns.
10. It is a reconstructed building that has been executed in a historically accurate manner on the
original site.
11. It is a creative and unique example of folk architecture and design created by person or
formally trained in the architectural or design professions, and which does not fit into formal
architectural or historical categories.
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Areas of Significance: (attach additional sheets if necessary)
Period of Significance: ____________________________ Significant Dates: ________ to ________
Significant Person: (complete if criterion #3 is marked above) ________________________________
Architect/Engineer: _________________________________ Builder: __________________________
State the significance of the property and reasons from items 1 -11 above in section 7: (attach
additional sheets if necessary)
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8. Major Biological References:
Bibliography: cite books, articles, and other sources used in preparing this form below. (attach
additional sheets if necessary)
9. Geographical Data:
Acreage of Property: _______________________
UTM References: (Universal Transverse Mercator)
A │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
Zone
Easting
Northing
B │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
Zone
Easting
Northing
C │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
Zone
Easting
Northing
D │______│_____▌____│____│____│____│____│____▌____│____│____│____│____│_____│
Zone
Easting
Northing
Legal Description:
10. Additional Required Documentation:
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Please list maps and photograph log in the order of attachments: (attach additional sheets if necessary)
Signature of Owner(s)
OWNER CONSENT FOR DESIGNATING AND LISTING
I (we) consent to the listing of the above property on the Town of Concrete Historic Landmark Register. I
(we) also certify being the legal owner(s) of the above property.
Owner Signature __________________________Print Name______________________ Date _________
Owner Signature __________________________Print Name______________________ Date _________
Owner Signature __________________________Print Name______________________ Date _________
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STAFF USE ONLY
1. Number of Resources within the Property:
Contributing
Non-Contributing
Buildings
Sites
Structures
Objects
Totals
Name of related multiple property listing: __________________________________________________
(enter N/A if property is not part of a multiple property listing)
Number of contributing resources previously designated as Town of Concrete Historic Landmarks: _____
2. Function or Use:
Historic Functions
Current Functions
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3. Description
Architectural Classification
Materials: ____________________________________________________________________________
Foundation: _________________________________ Walls: ___________________________________
Roof: _____________________________________ __Other: ___________________________________
4. Major Bibliographical Reference Documentation Checklist:
Previous Documentation on File
 Included in Town of Concrete Historic Resource Inventory
 Previously designated a Town of Concrete Landmark
 Listed in the Washington State Register of Historic Places
 Preliminary determination of individual listing
 (36 CFR 67) has been requested
 Previously listed in the National Register
 Previously determined eligible by the National Register
 Designated a National Historic Landmark
 Recorded by Historic American Building, Survey #_______
 Recorded by Historic American Engineering, Record #_________
Primary Location of Additional Data
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 State Historic Preservation Office
 Other State Agency
 Federal Agency
 Local Government
University
 Other _______________________________________________
5. Boundary Justification (if needed):
Received: ___________________
Town of Concrete Historic Preservation Commission Recommendation/Decision:
In the opinion of the Town of Concrete Historic Preservation Commission, the property does NOT
meet the Town of Concrete Landmark Register criteria.
Commission Chair Signature: ______________________________________________Date: __________
Town Planner Signature: __________________________________________________Date: __________
The Town of Concrete Historic Preservation Commission has reviewed the referenced application and
does hereby by recommend to the Town of Concrete Town Council approval of said property for
placement on the Town of Concrete Historic Landmark Register.
Commission Chair Signature: ______________________________________________Date: __________
Town Planner Signature: __________________________________________________Date: __________
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Town of Concrete Town Council Action:
The Town of Concrete Town Council gave its approval in the Town Council meeting of (Date)
__________
We hereby certify that this property has been listed in the Town of Concrete Register of
Historic Places:
___________________________________________________________
Judd Wilson - Mayor, Town of Concrete
___________________________________________________________
David Soule - Chair, Town of Concrete Historic Preservation Commission
=====================================================================================
Town of Concrete Town Council denied the application for placement on the Town of Concrete Register
of Historic Places:
___________________________________________________________
Judd Wilson – Mayor, Town of Concrete
___________________________________________________________
David Soule – Chair, Town of Concrete Historic Preservation Commission
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