Preservation Worcester
Historic Marker Application
Fill out as much information as you
know. Please type or print clearly.
Call 508-754-8760 for more information.
Date:___________
Section I
Current Owner / Marker
Applicant Information
Note: If this
application is being filled out for a non-residential marker; include the name
of the organization, and the name and title of the contact person in the first
blank provided.
1. Applicant?s Name:____________________________________________________________
2. Applicant?s
Telephone (list at least two numbers if possible):
Home:
________________________________________________________________________
Work:
________________________________________________________________________
Cell: _________________________________________________________________________
3. Applicant?s Fax:
_____________________________________________________________
4. Applicant?s
E-mail: ___________________________________________________________
5. Applicant?s
Mailing Address:
Street:
________________________________________________________________________
City:
___________________________________
State: ________________ Zip:
___________
6. Preservation
Worcester Member: _____ Yes _____ No
Section II
Original and Other
Significant Owners of the Structure
Research Information: Please include as much of this information
as possible. Identify the source of
information even if it from anecdote or legend. Preservation Worcester has building files that may be of
assistance.
1. Original
Owners(s);
Full Name: ____________________________________________________________________
Full Name of Spouse: ____________________________________________________________
Birth Dates: ___________________________________________________________________
Places of Birth: _________________________________________________________________
Marriage Date: _________________________________________________________________
Dates of Deaths: ________________________________________________________________
Occupations: __________________________________________________________________
Dates of Ownership: ____________________________________________________________
Source(s) of Information: _________________________________________________________
2. Other Significant
Owners(s):
Full Name: ____________________________________________________________________
Full Name of Spouse: ____________________________________________________________
Occupations: __________________________________________________________________
Dates of Ownership: ____________________________________________________________
Source(s) of Information: _________________________________________________________
Section III
Construction Dates and
Builders
1. Date of Construction: __________________________________________________________
2. Architect: ___________________________________________________________________
3. Builder: ____________________________________________________________________
4. Source(s) of Information: _______________________________________________________
Section IV
Modifications and Relevant
Information
1. Dates and Brief Descriptions of Major Architectural Changes: _________________________
______________________________________________________________________________
2. Source(s) of Information: _______________________________________________________
3. Pertinent Information about the Property, its Owners, Residents or History: _______________
______________________________________________________________________________
4. Source(s) of Information:
_______________________________________________________
Current Historic Designations of the Structure: ________________________________________
______________________________________________________________________________
Please note that the historic marker is assigned to a structure, not awarded to a person or family, and the marker stays with the structure even if the occupants change.
Please remit application to Preservation Worcester, 10 Cedar Street, Worcester, MA 01609