AtchASOW Atch12a SHPORequest for Project Review.pdf

Please mail the completed form and required material to:

State Historic Preservation Office 203 Administration Building 50 Sherburne Ave St. Paul, MN 55155

This is a new submittal

This is additional information relating to SHPO Project #: ____________ DATE:_________________

Please refer to the Instructions for Completing the Request for Project Review Form. Submit one Request for Project Review form for each project. Project submittals will not be accepted via fax or e-mail. For questions regarding the SHPO review process, please visit our website or contact Kelly Gragg-Johnson, Review and Compliance Specialist, at 651-201-3455 or kelly.graggjohnson@state.mn.us.

Project Title: ________________________________________________________________________________________

Project Address (or Location): _________________________________________________________________________

City / Township (circle one): ________________________ Zip: __________ County: ________________

Legal Description: Township ______ Range ______E/W (circle one) Section ______ Quarter-section ______

Project Contact Name: ____________________________________ Title: ___________________________________

Company/Agency: ___________________________________________________________________________________

Street Address: ___________________________________ Phone Number: ______________________________

City: _________________________ State: ______ Zip: ______________ Email: _________________________

Federal Agency (if applicable): _______________________________________________________________________ (Agency providing funds, licenses, or permits)

Permit or Project Reference #: _____________________________

State Agency (if applicable): _________________________________________________________________________ (Agency providing funds, licenses, or permits)

Permit or Project Reference #: _____________________________

Local Agency (if applicable): _________________________________________________________________________

(Continued on Reverse Side) https://mn.gov/admin/assets/R-C_Form_Instructions_SIMPLE_tcm36-327667.pdf https://mn.gov/admin/shpo/ mailto:kelly.graggjohnson@state.mn.us

A) REQUIRED FOR ALL PROJECTS

Write a detailed description of the proposed project. (See attached.)

Attach a map of project location, with project area(s) clearly marked. Road names must be included and legible.

B) Architecture

Are there any buildings or structures within the project area? Yes No

If No, continue to the Archaeology section below. If Yes, submit all of the following information:

List all buildings and structures within the project area and the year they were built. (See attached.)

Photographs of each building and structure located within the project area, along with a photo key. Include streetscape images, if applicable. All photographs must be clear, crisp, focused, and taken at ground level. Aerial photos are insufficient.

List known historic buildings or structures located within the project area (i.e., individual properties or districts which are listed in the National Register or which meet the criteria for listing in the National Register). (See attached.)

C) Archaeology

Does the proposed undertaking involve ground-disturbing activity? Yes No

If No, this form is complete. If Yes, submit all of the following information:

Attach the relevant portion of a 1:24000-scale USGS topographic map (photocopied or computer generated) with the project boundary marked.

Description of current and previous land use and disturbances: (See attached.)

Any available information concerning known or suspected archaeological resources within the project area.

(See attached.)

April 2018

CCC Commissary Warehouse (Building 223) was constructed in 1935