Application for Municipal Heritage Designation

Applicant Information Name of Applicant: Address: City: Province: Postal Code: Phone Number – Home: ( ) Work: ( ) Fax: ( ) E-Mail:

Subject Property Lot(s): Block: Plan No: Subdivision: Address: Zone:

Applicant’s Interest in the Property Registered Owner Representative of Owner } Include letter from owner indicating authorization to apply Option to Buy } Include letter from owner indicating authorization to apply

Present Owner (If different from Applicant) Name: Address: Phone Number – Home: ( ) Work: ( ) Fax: ( ) E-mail:

Designation Requested for (Check one or more as appropriate) Building Exterior only Portions of building interior Note: The designation will be registered against the whole of the property but may be applied more specifically to the building. Reason for Requesting Municipal Heritage Designation

This information should be detailed enough to allow City Council to determine the significance of the historic place. All applications are based on an assessment of heritage “significance” that can be defined by the architectural, historical, cultural, or social importance of the place. It is suggested that you include a “Statement of Significance” as part of your application.

Assistance with your research can be provided by the following agencies:

- Prairie History Room, Regina Public Library (RPL) 306-777-6011 - City of Regina Archives 306-777-7000 - Provincial Archives 306-787-4068 - Saskatchewan Architectural Heritage Society 306-359-0933 - Publications: Henderson’s Directory; Regina: the first 100 years published by Leader Post Foundation 565-821; and Historic Architecture of Saskatchewan ISBN-919781-13-6

Present Use of Buildings and Property (be specific)

Proposed Use of Buildings and Property (state exactly what you propose to do)

History of the Property (provide information below)

1. Date of Construction – See Building Permit Register at City of Regina Archives: 2. Chronological history of occupancy – See Henderson Directories at RPL: 3. Copy of “Goad’s” Fire Insurance Plans - See Provincial Archives: 4. Date of Archival Photograph(s) – See City of Regina and Provincial Archives: 5 References to occupants or property in the Leader Post - See RPL newspaper index:

Has this building been moved? No Yes Date: From where was it moved? Original Use: Other (elaborate): Who is responsible for regular maintenance: Site Photographs For a clear appreciation of the structure for which Municipal Heritage Designation is being proposed, all applications must include photographs, as detailed below:  all four sides (straight on views)  all four corners (showing two sides in each photo)  details of any areas where repairs or replacements are necessary  general view of overall property, showing structure in relation to the surrounding properties.

Submit completed form to: City of Regina Development Services Department Current Planning Branch 9th Floor, City Hall P.O. Box 1790, Regina, Saskatchewan S4P 3C8

Certification I hereby certify that the statements provided above and in any attached documents are true and correct. If any of the facts stated in this form change, I accept responsibility to inform the City of Regina Development Services Department.

______Signature of Applicant Signature of Owner (if different from applicant)

______Name (printed) Name (printed)

______Date Date