"Built Heritage Program Application" - New Brunswick, Canada

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Download "Built Heritage Program Application" - New Brunswick, Canada

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Built Heritage Program
Project #________
Incomplete form will be returned
(for office use only)
Section 1 (To be completed by all applicants)
1) Legal Registered Name of Organization
2) Contact Person
Mr.
Ms.
Mailing Address
Municipality/Community
Title of Contact Person
Province
Postal Code
Telephone Number
Fax Number
Web Site Address
Cell or alternate number
Major Activity of the Organization
E-mail
Reset
Built Heritage Program
Project #________
Incomplete form will be returned
(for office use only)
Section 1 (To be completed by all applicants)
1) Legal Registered Name of Organization
2) Contact Person
Mr.
Ms.
Mailing Address
Municipality/Community
Title of Contact Person
Province
Postal Code
Telephone Number
Fax Number
Web Site Address
Cell or alternate number
Major Activity of the Organization
E-mail
Section 2 (To be completed by all applicants)
Particulars of the Project
1. Project Title________________________________________
2. Location of Project__________________________________
3. Are you applying for; (check appropriate box)
Component A, Professional Design Services (
)
complete sections 3, 5 and 6
Component B, Capital (
)
complete sections 4, 5 and 6
4. Detailed Project Description (
)
attach all relevant documents
Section 3
Project Budget for Component A of the Program
(To be completed by Component A applicants)
Projected
Professional Design Service
Costs/Fees $
(list consultants below)
Total Professional Design Service Cost
Sources of Funds
Projected $
Federal
Provincial Built
Heritage Program
(up to 75%, to a maximum
Public Sector (specify)
of $5,000)
Other Provincial
Funding
Municipal
Private Sector
Applicant
Other
Total Funds
Estimated Start Date
Estimated Completion Date
Section 4 Project Budget for Component B of the Program
(to be completed by Component B applicants)
Project Costs
Projected Costs $
Professional Services
Acquisition
Demolition,
Excavation
Machinery/Equipment
Materials
Heritage
Conservation
Labour
Component Costs
Other (specify)
Machinery/Equipment
Materials
Other Project
Costs
Labour
Other Costs (specify)
Total Project Costs
Revenues/Sources of Funds
Projected $
Federal
Built Heritage
Program
(up to 50%, to a maximum
Public Sector (specify)
of $30,000)
Other Provincial
Funding
Municipal
Private Sector
Applicant
Other
Total Revenues/funds
Estimated Start Date
Estimated Completion Date
Section 5 (To be completed by all applicants)
Please provide the following:
• For both Components A and B:
o Business plan, organizational objectives and, if applicable, a projected program
and/or description of the re-use proposal for the building or site.
o Board resolution supporting the proposed project and application to this
program.
o Proof of ownership or long-term lease arrangement.
• For Component B:
o Rehabilitation plan with professional design, specifications and cost estimates.
o Indication that all federal, provincial and municipal environmental, fire and
safety standards will be met.
Section 6 Affirmation
I AFFIRM THAT the information in this application is accurate and complete and that the
project proposal, including plans and budgets, is fairly presented. I agree that once funding
is provided, any change to the project proposal will require prior approval of the Heritage
Branch. I also agree to submit a final report, and where required, financial accounting for
evaluation of the activities funded by the Department of Tourism, Heritage and Culture.
Instructions
• The project must not commence before the
Send all applications to:
applicant receives written notification of approval
Heritage Branch
by the Department of Tourism, Heritage and
Department of Tourism, Heritage
Culture.
and Culture
• The applicant shall allow representatives of the
P.O. Box 6000
provincial government to enter at all reasonable
Fredericton, NB E3B 5H1
times into the work area.
I certify that the information contained in this application is correct and I
accept to follow the instructions.
Name of Applicant (Please print)
Signature (Applicant)
Title
Date
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