Heritage Plaque Program Application Form

Thank you for your interest in the Township’s Heritage Plaque Program. This application is for owners of properties designated under the Ontario Heritage Act who wish to receive a complimentary heritage plaque recognizing their property’s historical significance. Applications are accepted year-round, and applicants will be notified of the status of their application within 10 business days of approval verification.

Is your property designated under Part IV of the Ontario Heritage Act? *

Property Owner Name *

First

Last

Property Owner Phone Number *

Property Owner Email Address *

Heritage Property Address *

Address Line 1

Address Line 2

City

Province

Postal Code

Are you the property owner? *

What was the original use of the property? (if known)

If use is not known, write “N/A”

Provide the name of the original owner, or owner of significance, and their spouse, if known.

If owner is not known, write “N/A”

Provide the occupation of the original owner, or owner of significance.

If occupation is not known, write “N/A”

designated for the

Provide the date of construction for the property.

If date of construction is not known, write “N/A”

Provide any drawings or photographs indicating the suggested area for plaque installation.

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

*Plaque must be installed so it does not cover, distract from, or damage any relevant heritage attributes.*

Provide any additional historical documents, photographs, etc. relevant to the designated property. (Not required)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Terms and Conditions:

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

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 acknowledge that the Township often uses photographs in its advertising and promotion of services and programs. I consent to the Township using the exterior photographs collected for future publications.

I acknowledge that any subsequent maintenance following the plaque installation is my responsibility. Including alerting Township staff when the plaque is in need of replacing.

I understand that a one-time fee is to accompany a complete application with any future plaque replacements being at the expense of the Township.

I acknowledge that Personal information on this form is collected under the authority of the Municipal Act and is maintained in accordance with the Municipal Freedom of Information and Protection of Privacy Act.

Signature *

Clear Signature

Terms and Conditions:

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