Road Events and Activities Temporary Road Closure / OFFICE USE ONLY
Register No:……………………….
Receipt Key / Type:187
Asset No:..………………………..
Amount Paid:$……..…………….
Date Paid:………….…………….
CS Officer:……...………………..
PART 1 – APPLICATION DETAILS
Please refer to Council’s Fact Sheet – Road Events / Activities and Associated Temporary Road Closures for information on what you will need to lodge with this application form. Failure to submit all necessary information may delay the processing of your application. You must provide a completed document checklist with your application. Fees are payable at the time of lodgement.
APPLICANT DETAILS
Name / Organisation / Company
Postal Address / PO Box / Telephone
Suburb / State / Postcode / Mobile
Fax / Email / Customer Reference
EVENT / ACTIVITY NAME
Name
STREET LOCATION OF ACTIVITY AND ROAD STATUS
Unit No / House / Property No / Street
Suburb
Location Within Road Reserve / Roadway / Footpath / Road Status / Classified / Unclassified
DATE & TIME OF ACTIVITY
Is the event a 'single date' or 'multiple date' event? / Single Date / Multiple Date
Date(s) / Start Time / Finish Time
ACTVITY TYPE
More than 500 participants and spectators (Development Application may be required)
500 or fewer participants and spectators
Police Controlled Event
Description of the proposed activity / event ……....………………………………………………………………………......
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provide separate page if required ……....………………………………………………………………………......
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No. of staff / volunteers / Expected number of attendees / Total
PART 2 – APPLICANT DECLARATION
I/We hereby apply for approval to undertake the proposed activity / event as described in this application and declare that I/We have read and fully understand Council’s Fact Sheet – Road Events / Activities and Associated Temporary Road Closures and that all the information in the application, checklist and supporting documentation is, to the best of my/our knowledge, true and correct.
Applicant(s) Name / Date
Applicant(s) Signature
PRIVACY NOTIFICATION
Personal and private information supplied to Council is managed in compliance with the Privacy and Personal Information Protection Act 1998. The supply of this information is not voluntary, as it is required by law in order to process your application/request. The intended recipients of the personal information are Officers within the Council, agents/contractor of the Council and other statutory authorities. You may apply for access or amendment to your personal information held by Council. You may also request that Council suppresses your personal information from a public register. If you have any further enquiries concerning this matter, contact Council on (02) 4993 4100, or the Information and Privacy Commission 1800 472679 or email mailto: or the website
PART 3 – APPLICATION CHECKLIST
CHECKLIST
Please confirm that you have provided the following information with your application, with reference to the requirements of the Fact Sheet – Road Events and Associated Temporary Road Closures, by placing “X” in the appropriate box below:
All contact information and details of the activity / event (section 5.1)
A site diagram (section 5.2)
A Traffic Management Plan (sections 5.3)
A Traffic Control Plan(s) (sections 5.3)
A Risk Assessment to confirm the existing and likely risks that may arise to event patrons and other road users asa result of the activity / event (section 5.3)
A copy of your Public Liability Insurance (section 5.3):
a) valid for $20 million and covering the intended period of the event or activity
b) noting Cessnock City Council as an “Interested Party”
Copies of approvals from other external authorities (section 4), such as:
“Form 1 – Notice of Intention to Hold a Public Assembly" form with lodgement confirmation from
the NSW Police Force
RMS Road Occupancy Licence Application
NSW Police Force approval
Approval to film (from Screen Hunter-Central Coast)
PART 4 – LODGEMENT& PAYMENT INFORMATION
HOW TO LODGE YOUR APPLICATION
Address the application to:
General Manager
Cessnock City Council
PO Box 152
CESSNOCK NSW 2325
How to Contact Us
Phone: (02) 4993 4100
Fax: (02) 4993 2500
Email:
Web: / Lodge in person
between 9am and 4pm at Council's Administration Building
62-78 Vincent Street
CESSNOCK NSW
Lodge by email
/ Office Hours
9am to 5pm Monday to Friday
*Payments are accepted until 4.30pm
Fees
Fees are calculated in accordance
with Council’s adopted Fees And
Charges.
Payment Method: Cash, by mail: Cheque or Money Order, EFTPOS or Credit Card (Bankcard, MasterCard or Visa – complete the section below)
CREDIT CARD PAYMENT AUTHORITY
Card Holder Phone Number
MASTERCARD / Card Number / _ _ _ _ / _ _ _ _ / _ _ _ _ / _ _ _ _
VISA / Expiry Date / _ _ / _ _
Name On Card / Signature
IF CREDIT CARD DETAILS PROVIDED THAN PART 4 OF THIS PAGE IS NOT TO BE SCANNED
All hardcopies to be destroyed according to procedures
Prepared by Design Delivery Version 1.0 Date 25.02.2016DOC2015/022657