Application For Monumental Work In Council Cemeteries Form Page 2
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2I declare that all monumental masonry work carried out by the undersigned is done so in accordance with
NZS 4242: 1995 New Zealand Standard for Headstones and Cemetery Monuments, in accordance with the
Central Otago District Council Operational Guide/Manual/Policy/info sheet and Best Practice in Cemetery
Conservation as set by Historic Cemeteries Conservation Trust of New Zealand.
Authority to be signed by the owner or Legal representative: __________________________________
I give my permission for the erection of the work identified above, and in consideration of Council permitting
the execution of such work on the above plot, I the undersigned INDEMNIFY and hold safe and harmless the
Council against all actions, proceedings, claims, demands, costs, losses and expenses whatsoever which
may be made on or instituted against or suffered by the Council in any manner whatsoever by reason of the
Council having consented to the execution of such work.
Name of Monumental Mason/Installer: ________________________________________________________
Signature of Monumental Mason/Installer: _____________________________________________________
Signature of Owner/Legal representative: _____________________________________________________
For Office Use Only
Authority to Undertake Monumental Work in a Council Cemetery
NCS Cemetery Record No.: ____________________ File No.: _________________________________
Date: ______________________________________
Application authorised by: _____________________
_________________________________
Signature
Title
Plot owner or legal representative advised work may commence:
Yes
Date: ________________
Inspection of Monumental Works
Date monumental work inspected: _______________ Compliant
Yes
No
Remedial action required: ________________________________________________________________
____________________________________________________________________________________
Plot owner or legal representative advised of remedial work required. Date: ________________________
Re-inspection of remedial action carried out to my satisfaction. Date: _____________________________
________________________ _________________________ _________________________________
Name:
Signature
Title
Cemetery Records Updated
Photographic record taken and uploaded
Yes
NCS Cemetery Record updated as required.
Yes
Application for Monumental Work in Council Cemeteries
Created 03/15
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