Form 10-168e HPCA SHPO Review & Recommendation Sheet Rehabilitation -

NPS Form 10-168e (06/2016) OMB Control No. 1024-0009

National Park Service

HISTORIC PRESERVATION CERTIFICATION APPLICATION

STATE HISTORIC PRESERVATION OFFICE

REVIEW & RECOMMENDATION SHEET

REHABILITATION – PART 2 / PART 3

SECTION 1. APPLICATION INFORMATON

Project Number

     

Property Name

     

Property Address

     

Certified Historic Structure? Yes Pending

Part 2

SHPO REVIEW SUMMARY

Preliminary (date)

     

No outstanding concerns

Applying for state tax credit

In-depth NPS review requested

Part 3 (Part 2 previously reviewed)

Applicant informed of SHPO recommendation

Completed rehabilitation work conforms to work previously approved

Completed rehabilitation work differs substantively from work previously approved (describe divergences from Part 2 scope of work in Section 5)

Date application received by SHPO

     

Part 3 (Part 2 not previously reviewed)

Date(s) additional information requested by SHPO

     

Amendment

Date complete information received by SHPO

     

Advisory determination that a phase meets the Standards

Date of transmittal to NPS

     

Property visited by State staff (dates): Before      , during      , and/or after       rehab.

SECTION 2. APPLICATION MATERIALS

Sent previously

Photographs Other (list):      

Attachments

Photographs Rolled plans Flat plans, large size Flat plans, 11” x 17” or smaller Other (list)      

Sent separately

Photographs Rolled plans Flat plans, large size Flat plans, 11” x 17” or smaller Other (list)      

Documentation remaining on file in SHPO (e.g., masonry repointing samples, specifications)

     

SECTION 3. SHPO RECOMMENDATION

     

, who meets the Secretary of the Interior’s Professional Qualification Standards has reviewed this application.

The rehabilitation work:

meets the Standards.

meets the Standards with concerns.

meets the Standards only if the attached conditions are met (Part 2 only).

does not meet Standard number(s)       for the reasons described in Section 5.

does not meet Standard number(s)       as completed, but could be brought into conformance with the Standards if the remedial work recommended in Section 5 is completed (Part 3 only).

warrants denial for lack of information.

is being forwarded without recommendation.

Date

State Historic Preservation Office Signature

This is a review sheet only and does not constitute an official certification of rehabilitation.

SECTION 4. ISSUES

Alteration of significant exterior features or surfaces

Alteration, removal, or covering of significant interior features or finishes

Window replacement

Changes in significant interior plan, spaces, or circulation patterns

Additions, including rooftop.

Other (explain):      

Extensive site work, adjacent new construction, or demolition of adjacent structures

SECTION 5. SHPO EVALUATION Explain the recommendation and any concerns, particularly issues checked in Section 3. Where denial is recommended, explain fully. For Part 3s, describe any work that differs substantively from the approved work. For Part 3s that do not meet the Standards as completed, describe remedial work, if any, that could enable the project to meet the Standards. Comment on notable aspects of the project, such as technical or design innovations, or creative solutions.

     

SECTION 6. NATIONAL PARK SERVICE EVALUATION

     

Date

National Park Service Signature

Project Number

     

Property Name

     

Property Address

     

These comments respond to the Historic Preservation Certification Application –

Part 2 Part 3 Amendment Advisory determination for a phase

     

Date

State Historic Preservation Office Signature

The National Park Service has reviewed this application and calls your attention to these recommendations or comments.

Date

National Park Service Signature

				Project Number	     
Property Name	     
Property Address	     
The rehabilitation of this property as described in the Historic Preservation Certification Application will meet the Secretary of the Interior’s Standards for Rehabilitation provided that the following condition(s) is/are met:      
Photographs documenting that the conditions have been met must be submitted with the Request for Certification of Completed Work. Any substantive change in the work as described in the application should be brought to the attention of the State Historic Preservation Office and the National Park Service in writing, using the Amendment/Advisory Determination form, prior to execution to ensure that the proposed project continues to meet the Standards.
Date		State Historic Preservation Office Signature
The National Park Service has reviewed this application and calls your attention to these recommendations or comments.
Date		National Park Service Signature

NOTICES

Privacy Act Statement

Authority: 26 U.S. Code § 47 - Rehabilitation credit; 26 U.S. Code § 170 - Charitable, etc., contributions and gifts.

Purpose: To enable the Secretary of the Interior to evaluate the historic significance of structures and whether the rehabilitation of such structures preserves their historic character. The primary use of this information by the Secretary of the Interior will be to certify to the Secretary of the Treasury that the applicant is eligible for Federal tax incentives for historic preservation. This application is used by the Interior Revenue Service to confirm that applicants for the tax incentives have obtained the certification concerning historic structures and historic rehabilitations that are required by law.

Routine uses: The information will be used by the National Park Service and the State Historic Preservation Offices and disclosed to the Internal Revenue Service to determine if the applicant is eligible for Federal tax incentives.

Disclosure: Voluntary, however, failure to provide the requested information may prevent or impede you from receiving consideration for the requested benefit.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is not needed.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) through the State Historic Preservation Officer in order to enable the Secretary of the Interior to gain the benefit of the State review of applications for Federal tax incentives for historic by owners of historic properties. Information collected on this form, including names and all written comments, is subject to disclosure. All applicable parts of the form must be completed in order to receive consideration for the requested benefit. A Federal agency may not conduct or sponsor, and a person is not required to respond a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection and assigned it control number 1024-0009.

Estimated Burden Statement

Public reporting burden for this form is estimated to average 5 hours per response when completed in association with NPS Form 10-168a (Part 2); 2.5 hours per response when completed in association with NPS Form 10-168b (Amendment – Advisory Determination); and 3.5 hours per response when completed in association with NPS Form 10-168c (Part 3), including the time it takes to read, gather and maintain data, review instructions and complete the form. Direct comments regarding this burden estimate, or any aspects of this form, to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Drive, Mail Stop 242, Reston, VA 20192. Please do not send your form to this address.

RECORDS RETENTION - PERMANENT. Transfer all permanent records to NARA 15 years after closure. (NPS Records Schedule, Resource Page 1 of 6

Management And Lands (Item 1.A.2) (N1-79-08-1)).