SUITE 1, LEVEL 2,

1-17 ELSIE STREET, BURWOOD, NSW 2134

P O BOX 240, BURWOOD, NSW 1805

TEL: 9911 9911 FAX: 9911 9900

WEBSITE: www.burwood.nsw.gov.au

REQUEST FOR A CERTIFICATE OF EXEMPTION
Under the Swimming Pools Act 1992
Subject Land
Address: ………………………………………………..
……………………………………………………………
Lot No & DP or Strata No: ……………………………. / OFFICE USE ONLY
Council Ref Pool No: ……………………...
Application Fee: $ ………………………….
Receipt No: …………………………………..
Date Received: …./…./……
NSW Registration No: …………………….
Applicant
Name: …………………………………………………………………………………………………………………
Address: ………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………….
Contact details:
Tel: ………………………………. Fax: ………………………………………….
Signature: ……………………………………. Mobile: ………………………………………
Owner Details & Consent
Name: …………………………………………………………………………………………………………………
(If not Applicant)
Address:……………………………………………………………………………………………………………….………………………………………………………………………………………………………………………….
Tel: ………………………………………
As owner(s) of the land to which this application relates, I/We consent to this application. I/We also consent for authorised Council Officers to enter the land to carry out inspections and take any photographs of the pool area.
Signature(s): ……………………………………….. Date: …./…./……
DETAILS FOR ACCESS
Name: …………………………………………………………………………………………………………………
Contact no. Tel: ……………………………………. Mobile: ………………………………………
Access Instructions: …………………………………………………………………………………………….
(If Any)

Application for Certificate of Exemption under Swimming Pools Act 1992

POOL DETAILS (please tick appropriate box)

Type of Pool: o Above Ground/ Inflatable o Outdoor In Ground

o Spa/ Hot Tub o Indoor

Year of Pool Construction/ Alteration: o Pre 1 Aug 1990 o 1 Aug 1990 – 31 Aug 2008

o 1 Sept 2008 – 31 March 2013 o After 31 March 2013

EXEMPTION REQUESTED: …………………………………………………………………………………

……………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………..

(If insufficient space attach on a separate sheet)

Note:

Pre 1990 pools, and Pre 2012 small, large, waterfront property pools compliant with past standards and Spas do not come under section 22 but have their own exemption requirements in the Legislation.

Exemption because the property is being sold is not acceptable.

REASONS TO SUPPORT REQUEST: ……………………………………………………………………..

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

(If insufficient space attach on a separate sheet)

IF YOU PROPOSE TO INSTALL ALTERNATIVE SAFETY MEASURES PLEASE CLEARLY DETAIL THESE MEARURES

……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………

(If insufficient space attach on a separate sheet)

PROPERTY SKETCH (Please attach Property Sketch on a separate sheet)

Required information shall include street name, north point, all existing buildings including their use, all existing fencing including height and type, any other child-resistant barriers to pool access and location of the pool.

NOTE

a)  Under the provisions of Section 26 of the Swimming Pools Act 1992 the applicant is entitled to appeal to the Land and Environment Court against the local authority’s within twenty eight (28) days of refusal of the application, and

b)  The local authority’s failure to determine the application within six (6) weeks after it is made is taken, for the purposes of any such appeal, to be a refusal of the application.

INSERT PROPERTY SKETCH HERE

TRIM No.: 14/21582 Page 1 of 3

Request for a Certificate of Exemption
Under the Swimming Pools Act 1992