OFFICE USE ONLY
Certificate No Date
Fees Receipt No
1. TYPE OF APPROVAL BEING SOUGHT Please complete Public Road Works (Section 138 of the Roads Act 1993)
Other Public Works (Section 68 of the Local Government Act 1993) Compliance Certificate
2. APPLICANT Applicant must complete the Applicant Declaration in Section 8 of this form Family Name or Company Name
Given Name or ACN Address
Suburb Postcode
Email Phone
Contact Name
If the applicant is a Company, please nominate a Contact Person who can be contacted during business hours to discuss this application
3. OWNER’S CONSENT Refer to Applicant Declaration in Section 8 of this form Owner
Address
Suburb Postcode
4. PROPERTY DETAILS This is the location of the development site Address
Suburb Postcode
Lot(s) DP(s)
Roads Act and/or Local Government Act Application
Made under Section 138 of Roads Act 1993 and/or
Section 68 of Local Government Act 1993.
5. DEVELOPMENT DETAILS Description of Proposal
Development Consent No. Date of Consent
Has consent been modified? No Yes Modification details
Estimated Cost of Work
6. LODGEMENT CHECKLIST Your application will be processed faster if you provide all necessary and correct information. Please complete
Yes No N/A
Detailed engineering design/construction plans and specifications Any compliance certificates to be relied on have been provided
Reference to Council’s specifications has been made in General Notes on the plan Statement certifying the plans have been endorsed by a Chartered Professional Engineer Details of consultation with public authorities concerning the provision of utility services Undergrounding of existing overhead services acknowledged on plan
All required State/Public Authority approvals have been obtained and copy has been provided Erosion & Sediment Control Plan (small sites) or Soil & Water Management Plan (large sites) Site Specific Dust Management Plan
Traffic Control Plan
Construction Management Plan Dilapidation Report
Pavement Design
Landscaping plan including street tree details that are consistent with Master Plan All necessary security bonds (as required by the consent) have been lodged Long Service Levy has been paid and evidence of payment has been provided
All consent conditions, as required prior to the issue of a construction certificate, have been satisfied Professional Indemnity Insurance for a minimum $5 million for all consultants involved in the project Public Liability Insurance for a minimum $10 million and full Workers Compensation Insurance as required by NSW law for all contractors involved in this project
All matters identified in Construction Certificate pre-check have been addressed
7. APPLICANT DECLARATION Please complete
I certify that I have obtained the consent of all owners of the land to which this application relates and that I am acting in accordance with the consent of all owners.
I understand that incomplete or deficient applications will be rejected.
I acknowledge this declaration is confirmation of my identity and intent in lieu of my signature.
Full Name Date
8. PRIVACY AND PERSONAL PROTECTION NOTICE
Purpose of Collection For delivery of subdivision & certification services in The Hills Local Government area Intended Recipients The Hills Shire Council staff
Supply If you choose not to supply your personal information, we may not be able to supply the services you seek
Storage The Hills Shire Council, 3 Columbia Court, Norwest NSW 2153
