Place nomination form

Name*

Address*

Postcode

Phone*

Fax

Email*

Has the owner/occupier been consulted?*

YesNo

Date*

Date

Name of place:*

Any former of other names:*

Address/loction:*

Please briefly explain the reason for contact

Local government authority:*

Lot/location:*

Diagram/plan:*

Reserve details/number:*

Certificate of title details (volume/folio):*

Vesting:*

Purpose of vesting:*

Please provide a brief description of the place and how to find the area of land you are nominating:*

Please upload a sketch plan or map showing the precise area of land you are nominating:*

Construction date:

Date

Design date (if known/relevant):

Date

Architectural style (if known/relevant):

Please tell us what you know of the history of the place:

Attach separate attachment outlining the history of the place if necessary:

Why do you think this place is important to the story of Western Australia?:

Reason for nominating place:

Original use (purpose for which the place was built):

Later and current use(s):

Type of place (select as many as apply):

Is the structure associated with any significant individuals? (e.g. architect, designer, builder):

Previous owners or occupants:

What theme of Western Australian history does this place fit into?:

Describe the place and its setting as clearly as possible (including any other associated buildings, gardens, plantings, boundaries, walls, notable features etc):

What other buildings or structures are associated with this place?:

What parts of the place are original?:

What major changes have been made to the place and when were they made?:

What condition is the place in overall?:

GoodFairPoor

Fibrous Cement, corrugated

Fibrous Cement, flat

Fibrous Cement

Asbestos Tile

Other Asbestos

Common Brick

Face Brick

Handmade Brick

Painted Brick

Pointed Brick

Rendered Brick

Two-tone Brick

Other Brick

Concrete Block

Concrete Slab

Pre-cast Concrete Panel

Reinforced Concrete

Other Concrete

Log

Tongue and Groove

Shingle

Slab

Weatherboard

Other Timber

Aluminium

Bronze

Cast Iron

Chrome

Cooper

Corrugated Iron (CGI)

Coloured CGI

Lead

Nickel

Pressed Metal

Steel

Tin

Wrought Iron

Other Metal

Fibrous Plaster Sheet

Plasterboard

Plaster, decorative

Lathe and Plaster

Set Plaster

Other Plaster

Bagged

Cement Dressed

Pebble Dash

Roughcast

Smooth

Other Render

Donnybrook Sandstone

Granite

Limestone

Local Stone

Marble

Sandstone, other

Slate

Stone Veneer

Terrazzo/Conglomerate

Other Stone

Glass

Acrylic Sheet

Aluminium Tile

Cement Tile

Encaustic Tile

Faience Tile

Glass Tile

Terracotta Tile

Tessellated Tile

Vinyl Tile

Other Tile

Adobe (Mud Brick)

Pise (Rammed Earth)

Wattle and Daub

Other Earth

Are there any other features? (e.g. fireplaces, stained glass or leadlight windows, floorings):

Are there any features in the garden or landscape? (e.g. mature or unusual trees, garden design or layout, outbuildings, plantings, artefact scatters [e.g. old bottles]):

Non-built places - other features:

Owner name:

Address:

Postcode:

Telephone:

Fax:

Email:

example@example.com

Is the property occupied:

YesNo

Occupier name:

Lease details (e.g. mining):

Please list any places in Western Australia which you know of that are similar to the place you are nominating:

Please supply current photographs of key elements/features, with site or building plans or sketches showing where each photograph has been taken:

A map showing the location of the place and the area/boundary of land you are referring MUST be provided:

Please supply details of any sources including the author, publisher, title and date and where the source is held (e.g. city of Fremantle local history collection):

Your nomination will not be accepted without those marked with an *

The Heritage Act 2018 defines cultural heritage significance as aesthetic, historic, scientific, social or spiritual value for individuals or groups within Western Australia. State significance is assessed by considering various factors. Each place has its own unique combination of factors which together establish its contribution to understanding the heritage of Western Australia.

(1) In determining whether a place has State cultural heritage significance the Council considers the following:

(a) its importance in demonstrating the evolution or pattern of Western Australia’s history;
(b) its importance in demonstrating rare, uncommon or endangered aspects of Western Australia’s heritage;
(c) its potential to yield information that will contribute to an understanding of Western Australia’s history;
(d) its importance in demonstrating the characteristics of a broader class of places;
(e) any strong or special meaning it may have for any group or community because of social, cultural or spiritual associations;
(f) its importance in exhibiting particular aesthetic characteristics valued by any group or community;
(g) any special association it may have with the life or work of a person, group or organisation of importance in Western Australia’s history;
(h) its importance in demonstrating a high degree of creative or technical achievement;
(i) any other characteristic it may have that in the opinion of the Council is relevant to the assessment of cultural heritage significance.

(2) A place may have cultural heritage significance despite lacking physical material that substantially contributes to its cultural heritage significance.

Please verify that you are not a robot*

Place nomination form

1. Your details

2. Place details and/or land description

3. Maps/plans

4. History and type of place

5. State themes

6. Physical description

7. Construction Materials

Asbestos

Brick

Concrete

Timber

Metal

Plaster

Render

Stone

Glass

Tile

Earth

8. Ownership/occupier of the place

9. Comparative Information

10. Supporting Information

11. Enclosure checklist

12. Factors used to assess cultural heritage significance