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Heritage Restoration and Preservation Grant Program application The Planning Department Address: Redmond City Hall 15670 NE 85th Street. Mailing Address: City of Redmond Planning Department, Kimberly Dietz, MS: 4SPL P.O. Box 97010 Redmond, WA 98073-9710 Instructions: • Fill out all information requested on this form in the space and format provided (unless otherwise noted on the form). You are strongly encouraged to read the grant guideline document available through the City of Redmond Planning Department or on line at www.ci.redmond.wa.us. Do not use smaller than 10 point uncondensed typeface. • Signatures of the applicant or authorized representative are required. • Submit the signed original and 3 copies of your application. Do not staple the original. Double sided copies are preferred. • Include one set of any support materials, such as firm qualifications, bids, letters of support, historic photos/copies, and project planning information. Do not attach copies of support materials to your application. . If you want materials returned to you following review of your application, please indicate what you want back, and include a self addressed stamped envelope for return of materials. Applicant Information: Please fill out the following depending upon whether you are and INDIVIDUAL/BUSINESS or an ORGANIZATION: Individuals Name: Businesses Street Address: City: Zip: Phone: Fax: e-mail: Social Security # or Tax ID ---PAGE BREAK--- - 2 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Organizations Organization Name: Director: Project Director: (if different from above) Street Address: City: Zip: Phone: Fax: e-mail: Date of Incorporation: Federal Tax Fiscal year end date: Project Information Project Title: Project Description Summary: Project Location: Amount Requested (Amount requested not to exceed $10,000 {unmatched} or $50,000 {matched}) Total Project Budget Previous Fiscal Year’s Operating Expenditures $ Previous Fiscal Year’s Revenues $ ---PAGE BREAK--- - 3 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Project Description and Concept: Explain the proposed project. What do you plan to do? When? How? Photos, plans, drawings, illustrations, building condition reports, or building inspections that are related to the proposed project may be included separately as support materials. Methodology: Describe how the proposed work complies with the applicable Secretary of Interior’s Standards for the Treatment of Historic Properties. ---PAGE BREAK--- - 4 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Qualifications: Resumes, firm qualifications, or other supporting documents may be included separately as support materials. 1. Name the project director, heritage specialists, consultants, contractors or any personnel involved in this project. 2. Describe the qualifications of the each as it relates to their ability to complete the project. If you have examples of similar successfully managed and administered project-based work, please cite those. Project Impact: Describe how project contributes to maintaining or enhancing Redmond's heritage. How does the project raise the visibility of heritage preservation in the community or region? Public Benefit: Describe any public benefit derived from this project. Will there be any increased building stability as a result of the project? Will the public have any form of access at the completion of the project? Will the project be visible from any public spaces? (Letters of support may be included separately as support materials.) ---PAGE BREAK--- - 5 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Budget Budget Narrative: Explain how the project budget was developed. If the budget presented in this application is a preliminary budget arrived at without firm bids, explain how the cost estimates were determined. Cost Sharing: Explain if any other sources of funding that you plan to use to complete this project. This may include funding such as corporate funding, loans, or in-kind donations. ---PAGE BREAK--- - 6 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Project Budget Project Expenses Cash In-Kind Evaluation Feasibility studies for major repairs, restoration, or building strengthening that includes engineering, architectural, or other consultant fees, and bid documents. SUB-TOTAL $0.00 $0.00 Design Includes architectural design, engineering, other consultants fees, schematics, construction drawings, and bid documents. SUB-TOTAL $0.00 $0.00 Construction/Renovation Budgets Cost breakdown, including sales tax. SUB-TOTAL $0.00 $0.00 Financing Costs SUB-TOTAL $0.00 $0.00 Other Costs Permits, insurance, bonds, etc. SUB-TOTAL $0.00 $0.00 TOTAL CASH $0.00 TOTAL IN-KIND $0.00 TOTAL BUDGET $0.00 Note: You may request a copy of this spreadsheet from the City. Similar forms will be accepted. ---PAGE BREAK--- - 7 – O:\KDietz\Historic\Historic Preservation\Grants\Program Material\GRANT application 2013.docx Project Budget (continued) Project Income Projected Income Amount Confirmed Applicant's Contribution Corporation or other business organization (Identify) Foundations/Other grants (Identify) Government Individual Other Amount requested from Heritage Restoration and Preservation Grant Total Projected Income: Total Funds Confirmed: Signatures: Each signatory declares that she or he is the owner or the authorized official of the owner, is authorized to make this application, and will assure that any funds received as a result of this application are used only for the purposes set forth herein. Signature Please print name and title if appropriate: