Project Review Cover Form
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2New York State Office of Parks, Recreation and Historic Preservation
Historic Preservation Field Services Bureau
Peebles Island Resource Center, PO Box 189, Waterford, NY 12188-0189 (Mail)
Delaware Avenue, Cohoes 12047 (Delivery)
(518) 237-8643
Rev. 5-05
PROJECT REVIEW COVER FORM
Please complete this form and attach it to the top of any and all information submitted to this office for review.
Accurate and complete forms will assist this office in the timely processing and response to your request.
This information relates to a previously submitted project.
If you have checked this box and noted the previous Project
Review (PR) number assigned by this office you do not need to
continue unless any of the required information below has
PROJECT NUMBER ____PR________
changed.
COUNTY ________________________
If you have checked this box you will need to
complete ALL of the following information.
2. This is a new project.
Project Name __________________________________________________________________________
Location ______________________________________________________________________________
You MUST include street number, street name and/or County, State or Interstate route number if applicable
City/Town/Village _______________________________________________________________________
List the correct municipality in which your project is being undertaken. If in a hamlet you must also provide the name of the town.
County ________________________________________________________________________________
If your undertaking* covers multiple communities/counties please attach a list defining all municipalities/counties included.
TYPE OF REVIEW REQUIRED/REQUESTED
(Please answer both questions)
A. Does this action involve a permit approval or funding, now or ultimately from any other governmental agency?
No
Yes
If Yes, list agency name(s) and permit(s)/approval(s)
Agency involved
Type of permit/approval
State
Federal
_________________________________________
_____________________________________________________
_________________________________________
_____________________________________________________
_________________________________________
_____________________________________________________
**
B. Have you consulted the NYSHPO web site at
to determine the preliminary presence or absence of previously identified cultural
Yes
No
resources within or adjacent to the project area?
If yes:
Was the project site wholly or partially included within an identified
Yes
No
archeologically sensitive area?
Yes
No
Does the project site involve or is it substantially contiguous to a property listed or recommended
for listing in the NY State or National Registers of Historic Places?
CONTACT PERSON FOR PROJECT
Name ______________________________________ Title ____________________________________________
Firm/Agency __________________________________________________________________________________
Address ________________________________________ City _______________ STATE
______ Zip ________
Phone (_____)_________________ Fax (______)____________________ E-Mail _________________________
** then select HISTORIC PRESERVATION then select On Line Resources
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