Section 68 Activity Application Form - Bland Shire Council Page 3
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1
2
3SECTION E
SECTION G
► COMMUNITY LAND
TRADE WASTE
►
• CONSTRUCTION DETAILS
TRADE WASTE
COMMUNITY LAND – ENTERTAINMENT &
TYPES OF WASTE TO BE DISPOSED OF:
ERECTION OF TEMPORARY STRUCTURE
Specific waste to be disposed of:
Description of the activity, component, process,
_________________________________
design or temporary structure:
____________________________________
DETAILS OF MANUFACTURER
____________________________________
Manufacturer (brand name):
Date: ______________________________
__________________________________
Proposed Hours: _____________________
Model Number: _____________________
NSW Health Accreditation Number:
Community Land:
__________________________________
__________________________
Note: A copy of a certificate of accreditation issued by the
Tank capacity: ______________________
Building Regulations Advisory Committee (within the
meaning of the Building Act 1993), if it is so accredited, or if it
is not, documentary evidence of any test procedures, results,
performances or appraisals relevant to the proposed
SECTION F
accreditation that have been obtained from a recognised
appraisal body.
►SOLID FUEL HEATER
►CONSTRUCTION DETAILS
SECTION H
SECTION C (CONTINUED)
INSTALLATION OF DOMESTIC SOLID
► OTHER
FUEL HEATING APPLIANCE
►CONSTRUCTION DETAILS
Details of installer (if different from applicant)
:
SECTION C (CONTINUED)
_______________________________________________
►CONSTRUCTION DETAILS
Name:
_______________________________________________
Address:
_______________________________________________
_______________________________________________
Phone:
_______________________________________________
Mobile:
Email:
Fax:
►ADDITIONAL INFORMATION
Details of appliance: _______________
License Number/Accreditation No:
Make:___________________________
PRIVACY AND PERSONAL
Model: __________________________
INFORMATION PROTECTION ACT 1998
Australian Standard Compliance Details:
(Section 10)
_______________________________________
The information you have provided with this
application is considered 'personal information' for
Note: Please attach plans detailing the location of
the
purposes
of
the
Privacy
and
Personal
installation within the premises and the location of fuel
Information Protection Act (PPIA) 1998, and is being
storage facilities.
collected as to enable an efficient and accurate
assessment of your application. The intended
recipients of the information are officers within
Council assessing the application, and any other
OFFICE USE ONLY
agent of Council. The information required by this
application is required by law, and failure to provide
Fee Type
Fee $
Job No.
the information requested will result in Council being
Sec 68 – B(Storm/Sewer) _________
4410-1506-0002
unable to process your application. You may make
Sec 68 – C(Septic Install) __________
application to access and correct the information
4410-1506-0004
you have provided by contacting Bland Shire
Sec 68 – C(Operate Septic)__________
4410-1506-0005
Council.
Sec 68 – D(Comm. Land) __________
4410-1506-0007
PLANS AND SUPPORTING
Sec 68 – E(Public Rd)
__________
4410-1506-0008
INFORMATION
Sec 68 – F(Other)
__________
4410-1506-0009
Please attach ALL of the plans and supporting
Inspection/FOC
__________
4410-1408-0000
information that is required for your application. Be
advised that Council cannot be held responsible for
Photocopy
__________
4410-1803-0000
any delays in processing arising out of inadequacies
in the material submitted in support of this
ap-
Total Fee
__________
Int. ___
plication.
Receipt No. ___________
Date. ___________
3
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