Title (Mr/Mrs/Miss/Ms) First Name/ Surname

Title (Mr/Mrs/Miss/Ms) First Name/ Surname


I/We hereby give notice in accordance with Building Regulation 12 (2) (a) of my intention to carry out the building work or material change of use described in Section 6

  1. Applicant’s Name

Title (Mr/Mrs/Miss/Ms) ------First Name/ Surname ------

Telephone No ------Email ------

  1. Applicant’s Address



  1. Agent’s Name andAddress


Telephone No ------Email ------

  1. Proposed start of work ------
  1. Builder (if known)

Name------Address ------

------Telephone No ------

  1. Address of proposed work


Post Code------

  1. Full description of proposed work including location with regard to existing dwelling



No of occupants ------Total floor area of proposed extension (m2) ------

  1. Proposed use of building/extension------


  1. Fire Precautions

Is the building or its intended use one which the Regulatory Reform (Fire Safety) Order 2005 applies or will apply after the completion of the building work ------Yes/No?

  1. Drainage

State means of:

Surface Water Drainage ------

Foul Water Drainage ------

Is the building/extension to be built over a public sewer/private drain? ------Yes/ No?

Is a septic tank to be incorporated in the system ------Yes/No? If Yes state size and location


  1. Planning Permission

Do you intend to seek Planning Permission? ------Yes/No?

If obtained, state date & application number ------,------

  1. Cost

Estimated Cost of Work £------

  1. Is the work for the benefit of the disabled?------Yes/No? If yes, the work may be exempt from fees
  1. Electrical Work

Please state if you propose to employ an electrician/contractor that is a member of the competent person scheme.------Yes/No? (If not, this will result in an additional charge )

  1. Does the work consist of more than one extension?------Yes/No?

Unless they are both progressing simultaneously, an additional charge may be incurred

  1. Are structural calculations being submitted?------Yes/No?

An additional fee may be required where structural calculations are necessary to establish compliance with the regulations

  1. Consent

Do you consent to the Local Authority extending the period of time for dealing with the plans to two months if necessary?------Yes/No?

  1. Conditions

Do you agree to the plans being passed subject to conditions if necessary? ------Yes/No?

  1. Plan Fee

The plan fee is required at the submission stage of the application. Please see website for pricing details. Please indicate payment amount enclosed or to be submitted £ ------

* Please note, the application will not be accepted unless the correct fee has been paid

  1. Inspection Fee

At the start of work, a single fee will be charged to cover the cost of all site inspections. You will be invoiced for this after commencement, unless you have arranged for your agent to pay the fee.Please indicate who the invoice should be sent to: Owner or agent? ------

  1. Additional Information

The following information is required; please indicate if you have attached any of the following information:

Block Plan to scale of not less than 1:1250 showing:

1. Size and position of the build/extension and its relationship to adjoining boundaries ------Yes/No?

2. The boundaries of the curtilage of the building together with the size, position and use of other buildings within the same curtilage ------Yes/No?

3. The width andposition of any street adjoining the boundaries of the curtilage of the building


4. Drawings to a scale of 1:50 or 1:00 ------Yes/No?

5. Access Statement ------Yes/No?

Particulars of:

1. The provision of exits, if Section 24 of the Building Act 1984 applies (This applies to public buildings only) ------Yes/No?

Please specify number of storeys ------


Applicant/Agent ------Date ------

PARTY WALL ACT:If the work involves an alteration to a wall which separates your property from that of your neighbour, or excavations are to be carried out near adjoining buildings or boundaries, you are likely to have a duty under the Party Wall Act 1996 to notify the owner of that property of your intensions. Any disputes arising over party walls etc. are civil matters, which should be resolved between yourselves and your neighbours

Northumbrian Water Ltd -EXISTING PUBLIC SEWERS AND COMMON DRAINS - The proximity of your proposal to any public sewers or common drain (including those defined under the Public Health Act 1936) should be checked by Northumbrian Water Ltd. Prior to commencement of works, please contact NWL on Tel: 0845 717 1100, by email ), or by visiting their website to address any issues relating to building over or connection to sewers or drains common to 2 or more properties.

Completed application forms can be returned to us via email, post or in person:



Thank you for the information given on this form. The information provided will be used to process your application and will be held and processed in accordance with the Data Protection Act 1998.

If you would like more information concerning the Data Protection Act please contact the Information Commissioner.