STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

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HERITAGE COUNCIL GRANTS PROGRAMSTREAM 1: STATE HERITAGE GRANT (SHG)

APPLICATION FORM

BEFORE YOU APPLY

Please confirm you meet the eligibility requirements of the program by completing the below eligibility checklist. By applying it is expected that you have read and under-stood the Heritage Grants Program Guidelines 2021-22 available on the Department of Planning, Lands and Heritage’s website.

THE PLACE SUBJECT TO THE APPLICATION:

is listed in the State’s Register of Heritage Places

is privately owned or managed

has been owned for 3 years or more or there is a leasehold of ten years or more

is covered by a comprehensive building insurance policy

THE APPLICANT:

is not a government agency or government-related entity

is able to provide dollar-for-dollar funding toward project costs

doesn’t have an active project under a previous Heritage Grants Program funding round

(if a not-for-profit) has applied to Lotterywest and been declined funding, it has been determined not eligible for current Lotterywest grant program or holds conscientious objection to receiving funds from lotterywest

THE PROJECT:

is to conserve or document significant elements of the place

will be guided by an appropriate heritage professional or consultant (as applicable to the project)

is not required by a Heritage Agreement or any order imposed by the local government

It is recommended that you contact the Department of Planning, Lands and Heritage to discuss your project before you submit a grant application.

IMPORTANT INFORMATIONThe application form should be read in conjunction with the Heritage Grants Program 2021-22 guidelines published on the Department of Planning, Lands and Heritage’s website. Applications to the program will only be accepted for projects that conserve or document a place that is listed on the State Register of Heritage Places (the Register), or promote heritage conservation. You can check which places are in the Register at http://inherit.stateheritage.wa.gov.au.

Projects require the guidance of a suitably qualified heritage professional or consultant. See the program guidelines for more information. Professional or consultant fees should be included in your application.

If you are not the property owner, you must provide a copy of the lease or a letter of from the owners granting you permission to apply on their behalf. Funds requested must be supported by quotations, a minimum of two quotes per project task should be provided.

A range of tasks do not attract funding under the State Heritage Grants stream, for example, projects commenced prior to the signing of a grant agreement, heritage interpretation, new additions, demolition of significant fabric and educational or promotional activities.

For the full list of ineligible tasks, please visit Heritage Councils Grants Program website.

For more information, please contact us on 6551 8002 or email HCWAincentives@dplh.wa.gov.au

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

THE PROPERTY

Place number: Place name:

Is the property on the State Register of Heritage Places? Yes No

Current status: Assessment program Permanent

Property address:

Current property owner(s):

Have you owned the property for more than 3 years? Yes No

Please provide a copy of the Certificate of Title or latest rates notice

Are you leasing the property? Yes* No *Attach a copy of the lease (If the applicant is a lessee, a letter from the owners acknowledging the grant application and proposed

project needs to be attached)

THE APPLICANT

Applicant name:

Applicant type: Natural person(s)

GST registered entity (eg. business)

Non-GST registered entity (eg. business not registered for GST)

Not-for-profit organisation (must be incorporated)* * if a not-for-profit and have been declined lotterywest funding or have an objection to seeking Lotterywest funding attach evidence of this

Applicant’s ABN (if applicable):

Trading name (if applicable):

Applicant’s postal address:

Suburb: Postcode:

Email:

Telephone: Mobile:

Please give a brief summary of the project (including current and future use, condition of the place, the community benefits and other outcomes of the project).

PROJECT SUMMARY

APPLICATIONS CLOSE 4PM FRIDAY 10 DECEMBER 2021 LATE APPLICATIONS WILL NOT BE ACCEPTED

PROPERTY AND APPLICANT DETAILS

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

Task description Preferred quote (required) Alternative (required) Alternative quote 2 Supplier name Amount (Inc GST) Supplier name Amount (Inc GST) Supplier name Amount (Inc GST)

1

2

3

4

5

6

7

8

TOTAL TOTAL (1) TOTAL (2)

Funding request* (50%)

* maximum funding request for conservation works projects should not exceed $40,000. Additional funding up to $100,000 may be requested if the project meets one or more of the Major Conservation Project criteria, see page 12 and the program guidelines.

WORKS PROJECT DETAILS

Is there a Conservation Management Strategy or Conservation Management Plan in place to guide the works?

Yes – Year published: No

Name of Nominated Heritage Professional:

Industry category: Registered Practising Architect/Architectural Corporation

Qualified structural engineer

Chartered Building Surveyor

Quoted cost of nominated Heritage Professional: $

Have you applied for Development Approval for the works or do the works relate to an existing Development Approval?

Yes No

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 1

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 2Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 2

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 3Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 3

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 4

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 5Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 5

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 6Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 6

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 7Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 7

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

TASK 8Location/room

Issue

please include labelled images of the issue as attachments to your application.

What appears to be the cause of the issue?

If you have sought professional advice regarding the cause and solution, please provide a copy of any reports/instructions issued.

What steps have you taken to address the cause or prevent damage?Include detail of any regular maintenance undertaken, including pest control (if appropriate).

What is your proposed solution to the issue? If the proposed solution has been recommended by an industry professional, please provide a copy of the guidance issued to you.

TASK 8

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

MAJOR CONSERVATION PROJECTSTo be eligible to apply to the Major Conservation Projects category your application must demonstrate strong heritage outcomes in one or more of the below areas. Please outline below the criteria that your project meets and provide detail on how the outcome(s) will be achieved.

A. The project re-activates a heritage place, or contributes significantly to its future reactivation for the purposes of heritage tourism, public benefit and enjoyment.

B. The project demonstrates a proactive response to natural disaster mitigation

C. The project supports economic recovery and job creation at the local or State level

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

Task description Preferred quote (required) Alternative quote 1 (required) Alternative quote 2

Supplier name Amount (Inc GST) Supplier name Amount (Inc GST) Supplier name Amount (Inc GST)

1

2

3

TOTAL TOTAL (1) TOTAL (2)

Funding request * (50%)

* Maximum funding request for conservation management planning projects should not exceed $10,000. A minimum of two quotes should be provided per task.

DOCUMENTATION PROJECTSIs there an existing Conservation Management Plan, Conservation Management Strategy or other applicable conservation planning document for the place?

Yes – Year published: No

If yes, have you previously provided a copy of the document to the Heritage Council of Western Australia, or was it partially funded by the Heritage Council of Western Australia?

Yes No

PROJECT TASK SUMMARY

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

GENERAL PROJECT QUESTIONSHow will your contribution to the project be met? Tick any that apply.

Private funding/personal savings

Business/personal loan

Fundraising activities

Other grants (please give detail of any grants already awarded or that you have applied for or intend on applying for)

Partnership with other organisations (please detail)

If this application is unsuccessful, how would the project be funded?

Will further conservation works (aside from routine maintenance) be required following the completion of this project? If yes, please provide detail of these tasks and indicate how they will be funded.

Please outline your building maintenance schedule.

Is there any relationship between the applicant and any of the contractors or consultants who have provided quotes?

Yes (please provide details below) No

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

Please ensure all pages are complete and you attach the below documents to your application when making your submission:

Current certificate of title, latest rates notice or copy of lease and owners approval as applicable

A copy of current comprehensive building insurance

Evidence your project has been declined funding from Lotterywest, is not eligible for funding assistance or a letter of contentious objection to receiving Lotterywest funding (not-for-profit organisations only)

One high resolution photo of the exterior of the place(s) to be used for publicity (if applicable)

Copies of quotations for all tasks

Copy of quotation for heritage professional fee (works projects only)

Labelled images of issue(s) (works projects only)

Copy of any professional advice provided on the project, or extract from conservation management plan supporting works (works projects only)

Copy of Development Approval if approval has been granted (works projects only)

APPLICATION ATTACHMENT CHECKLIST

Post to: Heritage Grants Program Department of Planning, Lands and Heritage Locked Bag 2506 Perth WA 6001

Deliver to: Department of Planning, Lands and Heritage Gordon Stephenson House Level 2 Reception, 140 William Street PerthEmail to: HCWAincentives@dplh.wa.gov.au

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STREAM 1: STATE HERITAGE GRANT (SHG) - APPLICATION FORM

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APPLICATIONS CLOSE 4PM FRIDAY 10 DECEMBER 2021 LATE APPLICATIONS WILL NOT BE ACCEPTED

SUBMISSION

Is there any additional information you wish to include or details you wish to draw attention to?

APPLICANT’S ACKNOWLEDGEMENT

All information provided is true and correct to the best of my knowledge, and I understand that any omission or false statement may result in the rejection of the application, withholding of grant funding or termination of the Grant Agreement.

I acknowledge that the Heritage Council of Western Australia or its representatives may check any of the information contained in this application and agree to provide any additional information they may request in order to assist with application assessment.

I understand that this is an application only and in no way guarantees funding under the Heritage Grants Program.

I acknowledge that successful applicants are required to engage a suitably qualified heritage professional or consultant, as applicable to the project, and enter into a Grant Agreement.

If I am successful, I agree to erect a sign (to be approved by the Grantor) at the entrance to the property outlining the project and funding assistance received.

I am aware that I may need to seek approval from the local government authority before undertaking any works or erecting signage at the property.

I understand that if successful, details of this grant will be made public and are subject to disclosure under the Freedom of Information Act 1992.

I grant to the Heritage Council of Western Australia, a perpetual, non-exclusive licence to display, copy or publish in print or electronic format, all photographs submitted and declare that the photographs are my work or I have full authority to grant such a licence.

I understand that any quotes provided by a person or company that has a direct relationship with the applicant must be fully disclosed at the time of application. I acknowledge that further quotes may be required and the application may be excluded if this disclosure is not provided.

Signature:

APPLICATION SUBMITTED BY:

Name:

Position:

Organisation: Date:

SUBMIT YOUR APPLICATION BY 4PM FRIDAY 10 DECEMBER 2021

Please ensure all questions have been answered and all attachments are provided.