Owner Company / Authority Agent of the Owner

Applicant Details

Owner Company / Authority Agent of the Owner

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Applicant Name
Postal Address
Suburb / State / Postcode
Contact Name
Email / Mobile

Details of Work

Dates of Occupation / Start Date / End Date
Description of Building Work
Description of Hoarding Structure
Location of Hoarding
Area of Public Space Occupied
Dimensions Required

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Accompanying Documents

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Has a Building Permit been issued?

Yes

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Has Consent and Report been issued?

Yes

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Site Plan attached if Consent and Report not issued

Yes

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Traffic Management Plan attached

Yes

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Public Liability Insurance current certificate attached

Yes

PLAN TO ACCOMPANY APPLICATION FOR PERMIT

Location of Council land and area of closure, occupation or use

Declaration by Applicant

I confirm that I have read the Fact Sheet detailing the conditions required to be complied with, in the issue of a Local Law Permit, and agree that I will comply with those conditions.

To my knowledge all necessary building and/or planning permits have been obtained.

Request invoice for payment of fees, to be issued on receipt of your application.

Signature of Applicant / Date
Print Name

Details required on plan

·  Street: road, highway, carriageway, lane, footway, footpath, square, court, alley, right of way and any part of a road reserve.

·  Nearest street intersection

·  Any street furniture, parking signs, bins, power poles, pits, bus stops/shelters, etc

·  Distance in metres remaining for pedestrians and/or cars whilst works are in place.

A minimum of 1.5m for pedestrians and 3m for cars must be maintained at all times.

North