Address: Telephone/Mobile Number: Email: Tax Reference Number: Date: Satisfactory of Yes: No: subcontractor tax compliance demonstrated: (if applicable)* *see for further details on tax clearance procedures for contractors/subcontractors If necessary, copy this page to include additional contractors/tradespersons 11. Declaration by I, the applicant, certify that: I understand and fulfil all the terms and conditions of the Built Heritage Investment Scheme 2017 The information provided in the application form and supporting documents is correct and I will notify the relevant authority if there is any change in that information I am providing at from my own private resources towards these works €________ My tax affairs are in order I understand that payment of funds by a local authority under this scheme does not imply a warranty on the part of the authority or the Minister for Arts, Heritage, Regional, Rural and Gaeltacht Affairs in relation to the suitability or safety of the works concerned or the state of repair or condition of all or any part of the structure concerned or its fitness for use. I understand that the authority or the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs may make any enquiries that it considers necessary to establish my eligibility for funding under this scheme, and that the local authority’s and the Minister’s decisions are final. Applicant’s Signature: _________________________ Date: ______________ 12. Checklist for Owners/Applicants (Insert Yes or No accordingly) The following must be included in all applications to local Local authorities Yes/No authority Yes/No Form A fully completed Site location map with location of works clearly marked in red Evidence of Tax Compliance submitted to local authority (if applicable) Written consent of owner for proposed works (if applicable) Method statement attached (if available at application stage)
Address: Telephone/Mobile Number: Email: Tax Reference Number: Date: Satisfactory of subcontractor tax compliance demonstrated: (if applicable)* Yes: No: *see for further details on tax clearance procedures for contractors/subcontractors If necessary, copy this page to include additional contractors/tradespersons 11. Declaration by I, the applicant, certify that: I understand and fulfil all the terms and conditions of the Built Heritage Investment Scheme 2017 The information provided in the application form and supporting documents is correct and I will notify the relevant authority if there is any change in that information I am providing at €________ from my own private resources towards these works My tax affairs are in order I understand that payment of funds by a local authority under this scheme does not imply a warranty on the part of the authority or the Minister for Arts, Heritage, Regional, Rural and Gaeltacht Affairs in relation to the suitability or safety of the works concerned or the state of repair or condition of all or any part of the structure concerned or its fitness for use. I understand that the authority or the Department of Arts, Heritage, Regional, Rural and Gaeltacht Affairs may make any enquiries that it considers necessary to establish my eligibility for funding under this scheme, and that the local authority’s and the Minister’s decisions are final. Applicant’s Signature: _________________________ Date: ______________ 12. Checklist for Owners/Applicants (Insert Yes or No accordingly) The following must be included in all applications to local authorities Yes/No Local authority Yes/No Form A fully completed Site location map with location of works clearly marked in red Evidence of Tax Compliance submitted to local authority (if applicable) Written consent of owner for proposed works (if applicable) Method statement attached (if available at application stage)