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Site Number: 9999999
Name of Surveyors: test
Date of Survey:
Address: 101
Number of Structures:
Construction Date:
Current Use of Primary Building:
Historic Use of Primary Building:
Style of Primary Building:



Number of Stories:
Width (bays):
Foundation Material:
Depth (rooms):
Structural System:
Wall Cladding Material:
Roof Shape:
Roof Material:

Decorative Details/Unique Features:
Evidence of Integrity Location/Materials:
Additions/Alternations to Primary Building:
Condition of Primary Building:
Observable Threats:
Compatibility with Adjacent Land Uses:
Potential NR Eligibility:
Evidence of Construction Date:

Other Comments/Salient Details:

Comments/Additions from Others:

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