7 ^       * 4 > > > > > ^ ^ ^ ^Request for SHPO Comment on a Department of Education Project This form is meant to be used in conjunction with its Instructions and the March 2005 Guidance Memorandum for Department of Education Projects. Please consult all three documents as you prepare your submittal. The appropriate documents and forms, including the Iowa Site Inventory Form are available at www.iowahistory.org/preservation/review_compliance/schools or from the Review & Compliance Coordinator (515.281.8743). Submit unsigned to: School Facilities Consultant, IA Dept. of Education, Grimes State Office Building, Des Moines, IA 50319-0146 They will forward signed form to: SHPO Review & Compliance Coordinator, 600 East Locust Street, Des Moines, IA 50319-0290 I. GENERAL INFORMATION This is a new submittal This is more information relating to SHPO R&C #: a. Property Name: b. Property Street & Number: c. County: City: Zip: d. Funding/Grant Program: Iowa Demonstration Construction: Fire/Life/Safety Construction Grant Grant Year: Other: e. Local Contact Person on Project: Contact Address: City: Zip: Contact Email: Phone: II. SCOPE OF WORK AND IDENTIFICATION OF HISTORIC PLACES a. Check the box(es) that appropriately describe the proposed undertaking. Attach the information requested in the Guidance Memorandum for that type of project. Keep in mind that some undertakings will involve more than one type of activity: Renovation of Existing School Facilities (Section 2) Additions to Existing School Facilities (Section 3) Demolition of Existing School Facilities (Section 4) (including substantial demolition conducted as part of renovation) Sale, Abandonment, or Other Non-destructive Method of Disposal of Existing School Facilities (Section 5) Construction of New School Facilities (Section 6) b. Please check box indicating whether you are specifically requesting an archaeological and/or architectural review of your project and include each of the items requested, in addition to the information requested in the Guidance Memorandum: Archaeology (project involves ground disturbing activities, demolition, or new construction outside the existing building footprint) Number of acres in APE Legal location: Section(s) Township(s) Range(s) Architecture (use cover letter and Iowa Site Inventory Form for additional information) Date(s) of construction for property III. Applicant Certification a. Please check the appropriate box indicating your finding and determination of effect (Check Only One). No historic properties will be affected (i.e., none are present or there are historic properties present but the project will have no effect upon them) No Adverse Effect to a historic property (i.e., a historic property is present and affected. However, the project either has no adverse effect on the historic property, or the applicant or other federally authorized representative will consult with the SHPO to modify the project or impose conditions to avoid adverse effects.) Adverse Effect to a historic property (i.e., a historic property is present and adversely affected. The applicant, or other federally authorized representative, will notify the Advisory Council on Historic Preservation and consult with the SHPO and other consulting parties to resolve the adverse effect.) b. I understand that the SHPO has 30 days from receipt to object to this finding, after which the applicants responsibilities under Section 106 of the Historic Preservation Act are fulfilled. Federally Authorized Signature: Date: Type name below , Iowa Department of Education IV. State Historic Preservation Office Comment Agree with the finding in section III above (move to readers file) See attached follow-up letter Object to the finding for reasons indicated in attached letter SHPO Signature: Date: 03/2005   uv~h>?ugFMN`gh",.56>@FGHls¿}xurm@@@*st |0;eq  I V } p |     4 ; H O Y `¿~yvq@+ ` a n  r s 5TVde{Jlnw~@@+>?gNh6Ht Ϳr_OE: hx( 8 $( P!#(  (  (! %(  #(( X#((   (   $( #(( @ h0 1f I | } p  a  r UJKǴ|sk^XM?  X$( h 8888( hh h 8 8'`8 88xd#('`8  x8 88h 88KŲs(@hh@@ @!@8(@hh@@ @!@8hp (hh@@ @!@8hhh@@ @!@8 h hh@@ @!@8hh@@ @!@8 h  @(@ table of authoritiescaption Body TextBody Text Indent 2Body Text Indent Body Text 2Body Text Indent 3 Document Mapb! @! @     @$     =/B