Heritage Permit Waiver Application Form

Property Owner's Name *

First

Last

Property Owner's Phone Number *

Property Owner's Email Address *

Property Roll Number

Example 23-01-000-000-00000-0000

Property Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Are you submitting on behalf of the property owner? *

Yes
No

Agent Name *

Agent Phone Number *

Agent Email Address *

Agent Address *

Address Line 1

Address Line 2

City

Province

Postal Code

What is the current use of the property? *

Ex. Business, residential, farming purposes.

A site plan or sketch showing the location of the proposed work on the property. *

Click or drag files to this area to upload. You can upload up to 10 files.

Provide a written statement of the proposed work/changes: *

Provide a written statement of how the change will not impact the property's heritage attributes: *

Photographs that depict the existing buildings, structures and heritage attributes that are affected by the application and their condition and context. *

Click or drag files to this area to upload. You can upload up to 10 files.

Any drawings, specifications, paint chips, or additional notes as necessary to fully explain the work to be undertaken.

Click or drag files to this area to upload. You can upload up to 10 files.

Is any part of the alterations or renovations taking place in a Conservation Authority regulated area? *

Yes
No

Attach approvals of authorities having jurisdiction (conservation authority, source water protection, etc.)

Click or drag files to this area to upload. You can upload up to 10 files.

Signature *

Clear Signature

Terms and Conditions:

I have reviewed the submission requirements and understand that incomplete applications will not be accepted.

I agree that I understand that all statements contained in documents filled in support this of this application shall be deemed part of this application.

I understand that submission of this application to the Township of Puslinch does not guarantee a complete application has been received. Further review of the application will occur, and the applicant may be contacted to provide additional information and/or resolve any discrepancies or issues with the application as submitted. The Municipal Clerk shall determine whether the information submitted forms a complete application.

I understand that staff that may require a site visit and may need to enter the property that is the subject of this application for the purpose of evaluating the merits of this application and grant staff permission to visit the property. During a site visit, photographs of the property may be taken for the purpose of evaluating the application. Property entry will be organized by Township of Puslinch staff with the owner or agent prior to entry.

I understand that where an agent has been identified, the municipality is authorized, but not required to contact this person in lieu of the property owner and the agent is authorized to act on behalf of the property owner for all matters respecting the application.

I understand and agree that the proposed work shall be done in accordance with this application and understands that the approval of this application under the Ontario Heritage Act shall only be the Heritage Permit Waiver and shall not be a waiver of any other provisions of any By-law of the Township of Puslinch or legislation including but not limited to the requirements of the Building Code and the Zoning By-law.

I understand that in the event this application is approved, any departure from the conditions imposed by the Municipal Clerk or Council of the Township of Puslinch, as the case may be, or from the plans or specifications approved by the Municipal Clerk or Council of the Township of Puslinch as the case may be, is prohibited.

I acknowledge that any change to approved drawings, however small, may require an amendment to the permit application and will be used to process heritage permit applications.

I understand that an affidavit or sworn declaration by the Owner/applicant is required to certify that the information required and provided is accurate.

I understand that the propsal must comply with all other application legislation and By-laws and that other approvals if required have been included in the information provided by the owner and/or the agent in this application.

I am familiar with and have read section 69 of the Ontario Heritage Act which makes it an offense to knowingly furnish false information in any application or in any statement, report or return required to be furnished under the Act or the regulations, or to fail to comply with any order, direction or other requirement under the Act.

I acknowledge that personal information on this form is collected under the authority of the Ontario Heritage Act and will be used to process heritage permit applications.

Signature *

Clear Signature