ARCHITECTURAL CONSERVANCY ONTARIO -

Request for Service

A. Client Requesting Service

* Name:

(If an organization, please give representative’s name and title as well as organization’s name)

* Address:

* City:

* Postal Code:

* Tel/Fax/email:

(A way for us to contact you.)

B. Description of Services Requested

Structural Analysis

Site Plan Review

Development Review

Condition Assessment

Architectural Merit

Evaluation of Historic Significance

Advice for Restoration

Recommendation for Future Uses

C. Details of Property or Site

Current Name:

Historical Name (if known):

Address:

City:

Postal Code:

Nearest Road Intersection:

Lot and Plan:

Property Owner's Name:

Owner's Address:

Owner's Telephone/Fax:

D. Contact Person at Property or for Site

Same as in Section A

Name:

Address:

City:

Postal Code:

Tel/Fax/email:

E. Urgency of Request

Recognizing the volunteer nature of the service, estimate the date on which your report is required . If the report is required urgently, please explain the reason for the urgency

F. Agreement

I/We request the services of PreservationWorks! and enclose a cheque made payable to the Architectural Conservancy of Ontario Inc. in the amount of $300.00.

I/We will also pay all out-of-pocket expenses that will be invoiced by the PreservationWorks! consultant who provides the service.

I/We confirm that any property owner on whose land the PreservationWorks! consultant must cross to carry out his/her fieldwork has given permission to enter.

I/We understand that the Architectural Conservancy of Ontario Inc. and its employees or agents are not liable for any damage relating to, or arising out of, the provision of PreservationWorks! service, including, without limiting the generality of the foregoing, any damages or claims for personal injury, death, loss of use, revenue or profit and/or property damage.

I/We agree to indemnify and save harmless the Architectural Conservancy of Ontario Inc. and its employees and agents against, and in respect of, any claim or proceeding which may be commenced against them or any liability that may be incurred by them by reason of the provision of PreservationWorks! service.

I/We know that the advice given is the best the PreservationWorks! consultant can give within the limited time constraints of the service and that the service does not replace the need for the services of an architect, engineer, landscape architect, urban planner, historian or other professional.

Please return the completed form and any maps, photographs and known historical information along with your cheque made payable to the Architectural Conservancy of Ontario Inc to:

Architectural Conservancy of Ontario
401 Richmond Street West, Suite 206
Toronto, ON M5V 3A8

For further information, please contact:
(416) 367-8075 / fax (416) 367-8630 / email: coo@arconserv.ca