HISTORIC LANDMARK NOMINATION FORM

COMMUNITY DEVELOPMENT DEPARTMENT
Planning Division
8310 Allison Avenue, La Mesa, CA 91941
619.667.1177

1. NAME

Historic:

and/or Common:

2. LOCATION

Address:

City:

State:

ZIP:

3. CLASSIFICATION

Category

District Building(s) Structure

Site Object

Ownership

Public Private

Both

Status

Occupied Unoccupied

Work in Progress

Public Acquisition

In Progress

Being Considered

Present Use

Agricultural Commercial Educational Entertainment Government Industrial Military

Museum Park Private Residence Religious Scientific Transportation Other (list below)

Other (explain):

4. Owner of Property

Name:

Address:

City:

State:

ZIP:

5. LOCATION OF LEGAL DESCRIPTION

Courthouse, Registry of Deeds, etc.:

Address:

City:

State:

ZIP:

6. REPRESENTATION IN EXISTING SURVEYS

Title:

Date:

Depository for Survey Records:

City:

State:

ZIP:

7. DESCRIPTION

CONDITION

Excellent Good Fair

Deteriorated Ruins Unexposed

Check One

Unaltered

Altered

Check One

Original Site

Moved

Describe the present and original (if known) physical appearance:

8. SIGNIFICANCE

Period

Prehistoric 1400-1499 1500-1599 1600-1699

1700-1799 1800-1899 1900-1999 2000-

Areas of Significance - Check and Justify Below

Archeology-prehistoric Archeology-historic Agricultural Architecture Art Commerce Communications Community Planning Conservation Economics Education Engineering Exploration/ Settlement Industry Invention

Landscape Architecture Law Literature Military Music Philosophy Politics/Government Religion Science Sculpture Social/ Humanitarian Theater Transportation Other (specify)

Specific Dates:

Builder/ Architect:

Statement of Significance:

9. SOURCES

10. GEOGRAPHICAL DATA

11. FORM PREPARED BY

Name:

Application Prepared by: