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450 Columbus Boulevard, Suite 5 | Hartford, CT 06103 | 860.500.2300 | cultureandtourism.org
PROJECT REVIEW COVER FORM
Updated 1/2018
This is: ☐ a new submittal ☐ supplemental information ☐ other Date Submitted:
PROJECT INFORMATION
Project Name:
Project Proponent:
The individual or group sponsoring, organizing, or proposing the project.
Project Street Address:
Include street number, street name, and or Route Number. If no street address exists give closest intersection.
City or Town: County:
Please use the municipality name and not the village or hamlet.
PROJECT DESCRIPTION
Describe the overall project in detail. As applicable, provide any information regarding past land use, project area size,
renovation plans, demolitions, and/or new construction. Note if this will included in a separate attachment:
List all state and federal agencies involved in the project and indicate the funding, permit, license or approval program
pertaining to the proposed project:
Agency Type Agency Name Program Name
☐ State ☐ Federal
☐ State ☐ Federal
☐ State ☐ Federal
☐ State ☐ Federal
If there is no state or federal agency involvement, please state the reason for your review request:
FOR SHPO USE ONLY
Based on the information submitted to our office for the above named property and project, it is the opinion of the
Connecticut State Historic Preservation Office that no historic properties will be affected by the proposed activities.*
Mary Dunne/Catherine Labadia Date
Deputy State Historic Preservation Officer
*All other determinations of effect will result in a formal letter from this office
450 Columbus Boulevard, Suite 5 | Hartford, CT 06103 | 860.500.2300 | cultureandtourism.org
PROJECT REVIEW COVER FORM
Updated 1/2018
CULTURAL RESOURCES IDENTIFICATION
Background research for previously identified historic properties within a project area may be undertaken at the SHPO’s office. To
schedule an appointment, please contact Catherine Labadia, 860-500-2329 or Catherine.labadia@ct.gov. Some applicants may find it
advantageous to hire a qualified historic preservation professional to complete the identification and evaluation of historic properties.
Are there any historic properties listed on the State or National Register of Historic Places within the project area?
☐ Yes ☐ No ☐ Do Not Know If yes, please identify:
Architecture
Are there any buildings, structures, or objects within the project area (houses, bridges, barns, walls, etc.)?
☐ Yes (attach clearly labelled photographs of each resource and applicable property cards from the municipality assessor)
☐ No (proceed to next section)
Are any of the buildings, structures or objects greater than 50 years old? ☐ Yes ☐ No ☐ Do Not Know
If the project involves rehabilitation, demolition, or alterations to existing buildings older than 50 years, provide a
work plan (If window replacements are proposed, provide representative photographs of existing windows).
Archeology
Does the proposed project involve ground disturbing activities?
☐ Yes (provide below or attach a description of current and prior land use and disturbances. Attach an excerpt of the soil
survey map for the project area. These can be created for free at: https://websoilsurvey.nrcs.usda.gov
☐ No
CHECKLIST (Did you attach the following information?)
Required for all Projects Required for Projects with architectural resources
☐ Completed Form ☐ Work plans for rehabilitation or renovation
☐ Map clearly labelled depicting project area ☐ Assessor’s Property Card
☐ Photographs of current site conditions Required for Projects with ground disturbing activities
☐ Site or project plans for new construction ☐ Soil survey map
Suggested Attachments, as needed
☐ Supporting documents needed to explain project ☐ Supporting documents identifying historic properties
☐ Historic maps or aerials (available at http://magic.lib.uconn.edu or https://www.historicaerials.com/)
PROJECT CONTACT
Name: Firm/Agency:
Address:
City: State: Zip:
Phone: Email:
Federal and state laws exist to ensure that agencies, or their designated applicants, consider the impacts of their projects on historic
resources. At a minimum, submission of this completed form with its attachments constitutes a request for review by the Connecticut
SHPO. The responsibility for preparing documentation, including the identification of historic properties and the assessment of
potential effects resulting from the project, rests with the federal or state agency, or its designated applicant. The role of SHPO is to
review, comment, and consult. SHPO’s ability to complete a timely project review largely depends on the quality of the materials
submitted. Please mail the completed form with all attachments to the attention of Environmental Review at the address above.
Electronic submissions are not accepted at this time.