Determination Of Significance Form - Architectural And Historic Structure Significance Determining Page 2

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Extent of intended demolition: _______Partial _______Full
Describe structure(s) to be considered for demolition and make reference to photographs submitted. If partial demolition
is intended, mark specific areas of planned demolition on each applicable photograph.
Type of structure(s):
Single-Family Dwelling
Multi-Family Dwelling
Commercial/Industrial Structure
______________________________________________
Accessory Structure
Other (describe) _
___________________________________________________
Present status: _______Occupied _______Unoccupied
Construction type:
Frame
Stone
Unit Masonry
Concrete
______________________________________________________
Other (describe)
Exterior material:
Wood siding
Brick
Stone
Block
Stucco
_____________________________________
Concrete
Other (describe)
Roof material:
Slate
Cedar shake
Wood shingle
Asphalt shingle
Built-up plies
Metal (type: ___________________________________________)
Synthetic
Other (describe) _________________________________________
Interior walls:
Plaster
Sheetrock
Masonry (type: ________________________________)
_______________________________________________________
Other (describe)
Height in stories: ____________________
Approximate age of structure(s) in years or date of construction: _____________________________________________
Describe, in detail, the reason(s) for the demolition request. (Use another sheet, if necessary)
Will the structure(s) be replaced? _______No _______Yes
If yes, describe the planned replacement and anticipated date of replacement. (Use another sheet, if necessary)
END OF REQUESTED INFORMATION
__________________________________________
_________________________________________
Signature of Applicant
Signature of Code Enforcement Officer
______________________________________________
_____________________________________________
Date
Date
(rev. 06-26-12)

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