Country Fire Authority Regulations 2014

S.R. No. 165/2014

SCHEDULE 13

APPLICATION FOR PERMIT TO BURN BY APRIVATE PERSON

(For Use during the Fire Season as declared by the Country Fire Authority)

  • For consideration of a permit to burn to be issued, this application form must be completed and returned to the Municipal Fire Prevention officer at least 2 working days prior to the proposed burn.
  • No burning off is permitted until an application has been assessed and a permit approved.
  • Unaccompanied children must not be allowed on the fire ground.

Duties imposed by the OHS Act 2004.

Where the burn is to be undertaken within a workplace or by employees or contractors of the applicant or by a self-employed person, all requirements outlined in the OHS Act 2004 must be complied with.

Given Name / Surname
Residential Address
Street
Applicant
Details / Suburb
State / Post Code
Telephone No.
Mobile No.
Email
Preferred contact times:

Note - If you are not the owner, give the name and address of the owner. You must also declare that you have notified the owner of this application.

Owner/Business Details / Name / Business Name
Address
Street
Suburb
State / Post Code
Telephone No.

I/We declare that I/we have notified the Owner about this application:

Applicant’s signature: / ______/ Date: ______

DETAILS OF PROPOSED BURN

If this application is for multiple locations please provide a map and map references describing the locations of the properties to be burned.

Address of Proposed Burn
Street
Suburb
State / Post Code
Description of Material to be Burned
Address of Proposed Burn
Street
Suburb
State / Post Code
Description of Material to be Burned
Address of Proposed Burn
Street
Suburb
State / Post Code
Description of Material to be Burned
To be completed by the Local Brigade Captain:
I……………………………………………………………. Captain,
of the………………………………………………………………………Brigade
Consider that a permit to
burn…………………………………………………………………………………… as applied for
(Type of Material)
by………………………………………………………………………………………………..should/should not be granted.
Additional conditions or reason why permit should not be granted:
…………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………
Captains Signature: …………………………………………………. Date: ………………………

DECLARATION

I______(please print) understand that the information provided above will be used in accordance with relevant legislation and declare that this information is correct to the best of my knowledge.

Applicant’s signature: / ______/ Date: ______
Name of Owner: / ______
Owners signature: / ______/ Date: ______

The above information is required to enable Moorabool Shire Council to process your application. It may be disclosed to other parties, such as referral authorities and residents who may be affected by the proposal.

This Personal Information is held by Moorabool Shire Council in accordance with the Privacy and Data Protection Act 2014