www. northwarks.gov. uuplanning
North Warwickshire
Borough Council
Application for listed building
Planning (Listed
) Act 1990
You can complete and submit this form electronically via the Planning Portal by visiting www.planningportal.gov.uUapply
Publication of applications on planning authority websites
Please note that the information provided on this application form and in supporting documents may be published on the
Authorit/s website. If you require any further clarification, please contact the Authority's planning department.
Please complete using block capitals and black ink
It is important that you read the accompanying guidance notes as incorrect completion will delay the processing of your application.
1. Applicant Name and Address
2. Agent Name and Address
Title:
Title:
Last name:
Last name:
Company
AeR <Cr.J
(optional):
Unit:
&sSou*tc!..
House
I number:
I
House
f----l
I
First name:
(optional):
Unit:
I
House
name:
I
House
I number:
House l-----__l
suffix:
I
House
name:
Address 1:
0o 8cr+
Address 2:
So.r.,rrnr
Address 3:
4\\,s oF t'l,tr
-s82-
Address 1:
Address 2:
Address 3:
.
Town:
Town:
County:
County:
Country:
Country:
Postcode:
I
Company
\en*.rcp.
suffix:
I
-rratq
z.kA
Postcode:
3. Description of Proposed Work
Please describe the
to alter, extend or demolish the listed
{O
(Zcrsoeg l+n O OOO*tr:- {BE W*cr,C Oe s>|& s\o.rlciue-O rN\64+}ftrL\ 4{v$ F\}faN&frt
ln" A r{At,}aL \.tfns ftn,"cnnrer @ aa,ea-rf- Goarc- , ft.orr{cs5 k}cqt {+t+|,."8A A^.,O
4nl,\OAC\arfr\61era
Ai)D
rrCfr)nf-+r Rcrr^lTr,ef
SDate:: 20'l 4-02-t 0 rS
S8sision: 5975 5
I
3. Description of Proposed Work (continued)
4. Site Address Details
Please provide the full postal address of the application site.
Has the work already
started without consent?
! ves d*o
lf Yes, please state when the
work was started (DD/MM/YYYY):
E
Unit:
House
name:
I;#'6'",.,
Pxg;*
Address 1:
ll.----] il,"#i: [--l
U(sr;"5a
tlrruerr3..f S\o.$Sr
Address 2:
Address 3:
(date must be pre'application submission)
the work been
completed without consent?
Has
[ves
Eruo
Town:
A?m'z-srns.
County:
tUOSu* 4.Otat-ttCncetAAe.
Postcode
d-V4 r ezf
(optional):
Description of location or a grid reference.
(must be completed if postcode is not known):
the date when the
work was completed (DD/MM/YYYY):
lf Yes, please state
(date must be pre^application submission)
6. Pre-application Advice
5. Related Proposals
Are there any current applications, previous
_
proposalsordemolitionsforthesite? [-J
Yes
d*o
lf Yes please describe and include the planning application
reference number(s), if known:
Reference
Description
number
Has assistance or prior advice been sought from the local
authority about this
application?
ffVes
E
ruo
lf Yes, please complete the following information about the advice
you were given. (This will help the authority to deal with this
application more efficiently).
Please tick if the full contact details are not
known, and then complete as much as possible:
tr
fficer
name:
6€€
Ch^^*.
Reference:
Date (DD/MM/YYW):
(must be pre-application submission)
Details of
A,Cg*ra{X,o-. 6xc
7. Neighbour and Community Consultation
Have you consulted your neighbours or
the local community about the proposal?
f ves Mruo
advice received?
t$z \s
t1trd/\cJ
8. Authority Employee / Membe_r
any of
' am: statements
apply to you?
staff
(b) an elected member
[l.-- Ves E{o
(c) related to a member of staff
with
respect to the Authority,
(a) a member of
I
(d) related to an elected member
Do
these
9. Materials
Please provide a description of existing and proposed materials and finishes to be used in the building (demolition excluded):
o,
E
Existing
(where applicable)
<tnO
o,4
Proposed
Don't
Know
cr
o
External walls
BCrrCj<*rr,r A^.G, csfl.tr..(-
Roofcovering
,fir-4- nr-rs f\s+o
Chimney
6n"..ra-.rcfi^o.
Windows
dmgsn- cillo,q*,t
L\
L\
tr tr
Lt
tt
tr
v\
t^
Ceilings
6c"te!s
lnternal walls
O^r.tl"co,>
t
Floors
("nosr.
k
lnternal doors
4"t.lgr:e
tA
Boundary treatments
(e.9. fences, walls)
{0Dtapr,.rs,P-^<
Vehicle access and
hard standing
tr tr
tr
q
T
4
tr tr
,(
u tr
tr tr
r/t
V
Noore
(b."'tqA{,- Gr u..2.
Lighting
tr
u u
u\
fO${
Aaf
tr
h
4"'.aea
Rainwater goods
r
vt
External doors
hAAtstrcD
tr tr
a4
v.
r
u
6l$r\r.iq
A.Ar
a(
tr
T tr
t^
a tr
Others
(add description)
Are you supplying additional information on submitted drawings or
plans? flVes
E
Uo
lf Yes, please state plan(s)/drawinq(s) references:
A A*.
6oseDu/ufl-
oc
7q,-ea+aa
\rs{
Bern"r
cfi.Grtutleo fio*L
lO aS
SBdd^a. 5975
S
10. Demolition
11. Listed Building Alterations
Does the proposal include the partial or
total demolition of a listed building?
Do the proposed works include alterations
to a listed building?
lf Yes, which of the following does the proposal involve?
lf Yes, do the proposed works include:
(you must answer each of the questions)
a)
Total demolition of the listed
building: I
ves
b) Demolition of a building within
the curtilage of the listed building:
c) Demolition of a part of the listed
E tto
@es
Eno
ffv"t
Eruo
c) Works to any structure or object fixed
to the property (or buildings within
its curtilage) internally or externally?
paes
f]
d) Stripping out of any internalwall, ceiling
orfloor finishes (e.9. plaster, floorboards)?
@ves
Euo
a) Works
building:
!
to the interior of the building?
b) Works to the exterior of the building?
Ves
lf the answer to c) is Yes:
i) What is the
W"t
total volume of the
listed building?(cubic metres)
ii) What is the volume of the part
to be demolished?(cubic metres)
iii) What was the (approximate) date of the
erection of the partto be removed? (MM/YYYY)
(date must be pre-application submission)
rno
lf the answer to any of these questions is Yes, please provide
plans, drawings, photographs sufficient to identiff the location,
Please provide a brief description of the building
building you are proposing to demolish:
or part of the
extent and character of the items to be removed, and the
proposal for their replacement including any new means of
structural support and state references for the plan(s)/drawing(s):
&-r-A-
S'\A
&M- grnsu"r *l
./c,Oe"".r.aD
Why is it necessary to demolish or extend (as applicable) all or part
of the building(s) and or structure(s)?
12. Listed Building Grading
13. lmmunity From Listing
Please state the grading (if known) of the building in the list of
Buildings of Special Architectural or Historic interest? (Note: only
one box must be ticked)
Has a Certificate
I
f]
ll*
[-l
Grade
Grade
Grade
ll
f
I
f]
lF
f
ll
I
Ecclesiastical Grade
Ecctesiastical Grade
Ecclesiastical Grade
Don't know
of lmmunity from Listing been sought in respect of
this building?
!
ves
Eltto
[-l
Don't know
lf Yes, please provide the result of the application:
l-l
SDate:: 201 +O2-l 0 aS SRevisbn: 5975
S
1
4. Ownership Certificates
One Certificate A, B, C, or D, must be completed with this application form
CERTIFICATE OF OWNERSHIP - CERTIFICATE A
Regulation 6 of the Planning (Listed Buildings and Conservation Areas) Regulationsl990
+<rtrT/The applicant certifies that on the day 21 days before the date of this application nobody except myself/the applicant
was the
owner* of any part of the land or building to which the application relates.
* "owner" is o person with a freehold interest or leasehold interest with
ot leost 7 years left to run.
Date DD/MM/WYY):
2u: a5.2st5
r,:'=f'T'tflt"f[,1]['TE::T'J;1::H'.ffIil*,
Resutations leeo
Resuration 6orthe
certify/ The applicant certifies that I have/the applicant has given the requisite notice to everyone else (as listed below) who, on the day
21 days before the date of this application, was the owner* of any part of the land or building to which this application relates.
* "owner" is a person with o freehold interest or leasehold interest with ot least 7 years left to run.
I
Name of Owner
Date Notice Served
Address
rslA
signed -
Applicant
or signed
-
Agent
Date DD/MM/YYYY):
CERTIFICATE OF OWNERSHIP - CERTIFICATE C
Regulation 6 of the Planning (Listed Buildlngs and Conservation Areas) Regulations 1990
I certify/ The applicant certifies that:
o
Neither Certificate A or B can be issued for this application
o
All reasonablestepshavebeentakentofindoutthenamesandaddressesoftheotherowners*
part of it but I have/ the applicant has been unable to do so.
* "owner" is a person with a freehold interest or leasehold interest with at least 7 years left to run.
Name of Owner
Address
Notice of the application has been published in the following newspaper
(circulating in the area where the land is situated:
Signed -
Applicant
Or signed -
Agent
ofthelandorbuilding,orofa
Date Notice Served
On the following date (which must not be earlier
than 21 davs before the date of the aoolication):
Date DD/MM/YYYY,):
1
4. Ownership Certificates (continued)
r,I[ll'j5'ffi,:f5,tHi:::t"1'5.;1t':Hi:fliP"*,
Resutation 6 or the
Resurations 1ee0
certify/ The applicant certifies that:
o
Certificate A cannot be issued for this application
o
All reasonable slgPs. have been taken to find out the names and addresses of everyone else who, on the day 21 days before the
date of this. application, was the ownef of any part of the land to which this appliiation relates, but I have/ the apfilicant has been
unable to do so.
I
x
'owner" is o person with a freehold interest or leasehold interest with ot least 7 years left to run.
The
taken were:
f.,l9tic9 of the application.has been published in the following newspaper
(circulating in the area where the land is situated):
Or signed - Agent:
15. Planning Application Requirements - Checklist
Please read the following checklist to make sure you have sent allthe information in support of your proposal. Failure to submit all
information required will result in your application being deemed invalid. lt will not be considered valid until all information required by
the Local Planning Authority has been
Tk6
rnzr 32 copies
zaniaa of
ar other
a+har plans
5^r drawings
A.^.,,i^^- ^The original
or
^,i^i^.r and
^r-^. and
information
necessary
describe
to
the
subject
of the application:
The original and 3 copies of a completed and
submitted.
t'
dated -J
M
The original and 3 copies of a plan which identifies the
which.the application relates and drawn to an J
!a.nd !9
identified scale and showing the direction of North: V
application
form:
[d
The original and 3 copies of the completed dated
Ownerihip Certificat6 (A, B, C, or D -'as
applicable):
The original and 3 copies of a design and access statement,
'
if requiiea (see help tbrt and gutdince noies ioi aiijitjl
D
U
l/we hereby apply for planning permission/consent as described in this form and the accompanying plans/drawings and additional
information. l/we confirm that, to the best of mylour knowledge, any facts stated are true arid aicuiate and any oplnions given are the
genuine opinions of the person(s) giving them.
DAIE (DD/MM/YYW):
24 . o,3. zo r5
17. Applicant Contact Details
18. Agent Contact Details
Telephone numbers
Country
f
code:
Telephone numbers
Extension
National number:
number:
Country
code:
Extension
number:
National numben
Country code;
f
Country code:
19. Site
Can
Visit
,/
the site be seen from a public road, public footpath, bridleway or other public
lf the planning authority needs to make an appointment to carry
out a site visit, whom should they contact? (Please select only one)
lf Other has been selected, please provide:
Contact name:
Email address:
land?
f]Aeent
l(r"t
Iruo
fleppticant
E 3J:itgfflfgi!:Hll,t3"