Fill in each box as instructed in the directions.
If information is unknown, then leave the box blank.
Try to give a concise description and history of the property.
Document your source of historic information in the Bibliography section.
Each part of the inventory sheet is to be completed as follows:
STATE MAP: In the extreme left hand corner of the first page is a map of West Virginia with
county divisions shown. Please fill in with the RED pen or pencil the county in which the site is
STREET ADDRESS: Give the street address, (i.e., 101 Main Street) or the county or state Route
number. If possible include the rural address (i.e., Route 1, Box 25). If not directly on a roadway
then use – i.e., “Off State Route 10.”
COMMON/HISTORIC NAME/BOTH: Place an “x” over the circle, or color the circle in to
indicate if the name is a common name or historic name, or both. A property’s “historic name” is
a formal designation and should reflect the event(s), or family, from which it derives its historic
significance. The “common name” would be the designation by which the property is most
generally known in the locale. In some cases the names may be the same.
FIELD SURVEY #: Consultants should place the number of the site assigned when in the field.
This may correspond to the map number.
SITE # (SHPO ONLY): This is for office use only.
TOWN OR COMMUNITY: Give the name of the closest town, or community. You may say
“Vicinity of.”
COUNTY: Give the name of the county where the site is located.
NEGATIVE NUMBER: If available enter corresponding black and white negative number.
This is mandatory when site is part of a large survey.
NR LISTED DATE: If applicable enter the date the property was listed on the National
ARCHITECT/BUILDER: Enter the name of the person responsible for the design of the
building, if known. Please indicate “architect” or “builder.”
DATE OF CONSTRUCTION: Enter date property was constructed. If this is a guess or an
approximation, put “circa” or “c” preceding date Circa indicates the approximation is ten years
before or after date.
STYLE: Office Use Only.
EXTERIOR SIDING/MATERIALS: Enter the outside covering on the building – stone, log,
brick, clapboard, aluminum or vinyl, etc. If not a building, then enter main material of construction,
i.e., steel bridge trusses.
ROOFING MATERIAL: Enter roof material – wood shingles, asphalt shingles, rolled asphalt,
rubber membrane, slate, clay tile, corrugated metal, standing seam metal roof. For bridges enter
deck material – wood deck, concrete, metal.
FOUNDATION: Enter foundation material – stone, stone piers, concrete block, glazed tile block,
poured concrete, lumber posts. For bridges enter pier material – stone, concrete.
PROPERTY USE OR FUNCTION: This indicates how the property is currently being used.
Place an “x” or color in the circle residence or commercial property. Use a key work for “other”
type of property: school, church, bridge, industrial or park. You may also use vacant. Indicate any
previous uses.
UTM NUMBER: If possible calculate a UTM number for the location of the property or plan to
include a map. UTMs are required for EACH SSITE for all projects by consultants.
QUADRANGLE NAME: Enter the name of the United Sates Geological Survey Topographical
Quadrangle Map where the property is located, if known.
SURVEY ORGANIZATION & DATE: Name the organization with who individual filling out
the form is associated (i.e., company name, historic landmark commission, historical society).
PART OF WHAT SURVEY/FR#: Name of the project the survey is associated with – i.e.,
Downtown Bluefield Survey; US 522; Roane County Survey. Consultants should place the FR# in
this location.
PHOTOGRAPH: Staple a 2” x 3” archival black and white photograph in the appropriate box on
the inventory form. If using 3” x 5” photo you may staple at the bottom of the page. Using a soft
lead pencil, write some identifying information on the back of the photo – name of the structure or
site, the negative number, etc. This is to assure the photo is not lost if it becomes loose. Staple
additional photos on continuation sheets.
SITE PLAN: Using the large white space at the bottom of the front page, include a site plan of the
property, showing its relationship to its immediate environment. Include streets, alleys, rivers,
streams, principal building, outbuilding, etc. The arrow indicates that north is at the top of the page.
SITE NUMBER: This is for office use only.
PRESENT OWNERS AND ADDRESS: This is self-explanatory.
DESCRIBE SETTING: Give a rough description of the property’s setting – city lot; rural farm,
hillside, river front. Describe trees, rock faces or any landscape features that are present. Estimate
the number of acres. Indicate if known archaeological artifacts are present and describe current
DESCRIPTION OF BUILDING OR SITES (Original and Presents): Describe the current and
historic physical appearance of the building(s), structure or site. The description should be concise
and as specific as possible. Begin with the number of stories and bays (or openings) on the first
floor of the front of the front façade. Indicate the shape of the plan, such as square, rectangle, L or
T-shape. Describe the porches and materials of construction. For bridges or structures, indicate
the style of construction and estimate length and width, give the decking and foundation (pier)
ALTERATIONS: Check appropriate box. If answer is yes, please describe the type of addition
time period, any materials of construction.
ADDITIONS: Check appropriate box. If answer is yes, please describe the type of addition, time
period and material constructions.
DESCRIBE ALL OUTBUILDINGS: Give a total number and a brief description, including
function of all outbuildings included with the property. Describe all outbuildings with date, siding,
roof and foundation. Examples of outbuildings include: garages, barns and sheds.
STATEMENT OF SIGNIFICANCE: How is the property important to the historic or cultural
development of the community or state? For what area of history is it important? (i.e., early
settlement, agriculture, military, industrial, educational, political or architecture.) What time period
was it active and vital? Who was responsible for its design and construction; who lived in the
building or used it; and what impact did it have on historic developments; did any events of historic
significance take place at the site? Even unverified dates and details gathered from occupants and
neighbors should be recorded.
The building should be placed in some context. Describe any way the building is distinguished
from those around it; largest or smallest block, more ornate in the neighborhood, one of the few
brick houses in the community, etc. If the building is typical or others nearby, then that should be
BIBLIOGRAPHICAL REFERENCES: Indicate any and all resource materials used in obtaining
the information contained on the form; books, official records, manuscripts, wills, family Bibles,
and any and all personal interviews along with the date. Be sure to indicate where the source of
material is presently located.
FORM PREPARED BY: Give the name of the person who typed or filled out the form, their
address and phone number. Give the date the form was typed.
CONTINUATION SHEETS: Please use continuation sheets for any additional information you
are not able to fit into the space on the form. Continuation sheets are used for extra photographs.
Consultants: Statements for Criteria and National Register eligibility should be placed on
continuation sheets and not on the inventory form.
Return form to: Survey Coordinator, WV SHPO, The Cultural Center, 1900 Kanawha
Boulevard, East, Charleston, WV 25305-0300
West Virginia Division of Culture and History
State Historic Preservation Office
This program receives federal funds from the National Park Service. Regulations of the U. S. Department of the Interior
prohibit unlawful discrimination in department Federally Assisted Programs on the basis of race, color, national origin, age
or handicap. Any person who believes he or she has been discriminated against in any program, activity, or facility operated
by a recipient of Federal Assistance should write to: Director, Equal Opportunity Program, U.S. Department of the Interior,
National Park Service, P.O. Box 37127, Washington, D.C. 20013-7127.