HomeMy WebLinkAboutEZ1 FORM - 106 fillable (rev July2021).pdfprotect the past, shape the future
DEPT OF ARCHAEOLOGY +HISTORIC PRESERVATION
Section 106EZ-1 FORM
Request to initiate consultation for Undertakings subject to Section
106 of the National Historic Preservation Act and 36 CFR 800.
For non-cultural resource professionals only.
revised April 2021
New Consultation?YES NO ADDITIONAL INFORMATION PROVIDED PER REQUEST
Questions?
Submitter Name:
Submitter Address:
Submitter Phone:Submitter e-mail:
City / State / Zip:
Submitter Organization:
SECTION 4: CONTACT INFORMATION
There are NO HISTORIC PROPERTIES
AFFECTED by the Undertaking.
The Undertaking will have NO ADVERSE
EFFECT on historic resources.
The Undertaking will have an ADVERSE
EFFECT on historic resources.
FEDERAL AGENCY DETERMINATION
DAHP USE ONLY
Date Received:
DAHP Log #:
Reviewer(s):
ARCHY BEU
SECTION 5: ATTACHMENTS
Please email completed form
and all attachments to:
106@dahp.wa.gov
SITE PLAN / DRAWINGS - Indicate location and dates of resources,
proposed improvements and ground disturbance, etc.
MAP / APE - Be sure to show the project boundary and location
of property(ies). See Section 7 on Page 3 for optional template. May
also submit online through WISAARD using eAPE.
DESCRIPTION / SCOPE OF WORK - Describe the Undertaking,
including any ground disturbance. See Section 6 on Page 2 for
optional template.
PHOTOGRAPHS - Attach digital photographs showing the project
site, including images of all resources.
Photos submitted through WISAARD may suffi ce.
Undertaking Title:
Property Name:
Project Address:
Township / Range / Section:City / State / Zip:County:
SECTION 1: DESCRIBE THE UNDERTAKING
leave blank if unsure
if applicable
YES NO
Check here if Undertaking involves multiple resources. If so, attach a
table including all information in Sections 1 and 2 for each resource.YES
YES YES
YES
YES
NEW CONSTRUCTION DEMOLITION GROUND DISTURBANCE REHABILITATION / RENOVATION ACQUISITION
NO
NO NO
NO NO NOT SURENOT SURE
Undertaking includes (check all that apply):
Has a project already been started in WISAARD?:eAPE?If so, DAHP log #:
Does the Undertaking involve any buildings, objects,
sites, structures or districts that are over 45 years old?
Does the Undertaking involve any
properties determined eligible for
or listed in the National Register of
Historic Places?
Is the building, structure or site
already recorded in WISAARD?
[!] If the resource is not recorded in WISAARD,
please contact DAHP Staff.
Go to www.dahp.wa.gov/wisaard for more information.
Check the box when complete.
If Yes, what is the
Property ID # or Site #?
*Contact DAHP[!] See Note
SECTION 2: IDENTIFY HISTORIC PROPERTIES
Federal Agency:
Contact Person:Phone:e-mail:
Grant / Loan Name:
SECTION 3: FEDERAL AGENCY INFORMATION
Contact DAHP at 106@dahp.wa.gov or (360) 586-3065.
You may also fi nd answers to your questions online at www.dahp.wa.gov/section106.
If different from Federal Agency contact person.
The Undertaking will have NO EFFECT on
historic resources.
Do you have authority from the Federal Agency to consult on their behalf?
DAHP REVIEWER DATE
DAHP requires ADDITIONAL
INFORMATION in order to complete
review (see attached).
SHPO CONCURRENCE (DAHP USE ONLY)
CONCUR
DO NOT CONCUR
AREA OF POTENTIAL EFFECT (APE)
See attached for additional information.
CONCUR
DO NOT CONCUR
DETERMINATION OF ELIGIBILITY
See attached for additional information.
CONCUR
DO NOT CONCUR
DETERMINATION OF EFFECT
See attached for additional information.
protect the past, shape the future
DEPT OF ARCHAEOLOGY +HISTORIC PRESERVATION
revised April 2021
SECTION 106 EZ-1 FORM
2
NOTE: To save this fi llable form you must fi ll it out in Adobe Acrobat or use the PRINT to PDF function in Acrobat Reader. In Reader choose File >
Print and choose Adobe PDF as the printer. The fi ll will save to your computer.
Please be aware that this form may only initiate consultation. For some projects, DAHP may require additional information to complete our review
such as plans, specifi cations, and photographs. An historic property inventory form may need to completed by a qualifi ed cultural resource
professional.
Instructions: Please describe the type of work to be completed. Be as detailed as possible to avoid a request for additional information. Be sure to
describe all ground disturbing activities in the appropriate box below, and provide photos of areas of work.
Provide a detailed description of the proposed project:
Describe the existing project site conditions (include building age, if applicable):
If there are ground disturbing activities proposed, describe them including the approximate depth of ground disturbance:
SECTION 6: ADD’L PROJECT INFORMATION
protect the past, shape the future
DEPT OF ARCHAEOLOGY +HISTORIC PRESERVATION
revised April 2021
SECTION 106 EZ-1 FORM
3
SECTION 7: MAP / Area of Potential Effect
CLICK IN THIS BOX TO ADD A MAP
MAP MUST BE IN JPEG FORMAT
SEE LINK ABOVE TO INSTRUCTIONS FOR CREATING A JPEG MAP
WITH THE SNIPPING TOOL FOR WINDOWS
Instructions: Please attach a MAP of the Project Area. (Use WISAARD with USA Topo Basemap background. Click HERE for Snipping Tool Tutorial. Draw an
outline of the Area of Potential Effect (APE) that clearly delineates the project boundary.