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HeritageMaintenanceRequest / Planning Reform/ Nov-15 Page 1 of 2
Request for Maintenance and/or Minor Works Affecting a Heritage Item or Conservation Area
Request under Clause 5.10(3) of the TLEP 2014 and TCCLEP 2012, for the written authorisation to undertake minor works and/or maintenance to a heritage item or a place with a heritage conservation
area without consent.
A1. Applicant
Surname/s Given
Name/s OR
Company/
Organisation
ABN
Return Mail Address
Telephone Mobile
Facsimile Email
A2. Owner’s Consent
The signed consent of all owners is required and must be submitted with this.
Name/s ALL owners (please print) Company (if applicable) Signature/s ALL owners
A3. Property Description
Lot No Section DP/NPP/SP
Name of Property (if any)
Unit/Street No Street
Suburb/Town
A4. Applicable Heritage Listing
Heritage Item Item Number Conservation Area
Request for Maintenance and/or Minor Works Affecting a Heritage Item or Conservation Area
Page 2 of 2 HeritageMaintenanceRequest / Planning Reform / Nov-15
A5. Description and Extent of Proposed Work
Please describe what works will be undertaken and what materials altered, repaired or replaced.
A6. Supporting Information/Attachments
Please cross what attachments are included with your request (may be provided on separate pages) Plans
Elevations Photographs
Samples of finished materials and paint colours
Streetscape analysis if works to the front of the building/structure
A7. Applicants Declaration
I declare that all the information in this application is true and correct.
I understand that if the information is incomplete the application may be delayed or rejected.
Applicants Name (please print)
Applicants Signature Date
(OFFICE USE)
Authorisation granted Date Land No
Authorisation denied Date