SUITE 1, LEVEL 2
1-17 ELSIE STREET BURWOOD NSW 2134
PO BOX 240, BURWOOD NSW 1805
TEL: 9911 9911 FAX 9911 9900
WEBSITE: www.burwood.nsw.gov.au
application for works on council property
1.0 APPLICANT’S DETAILS
Name: …………………………………………………………………………………………………………..
Company Name: ………………………………………………………………………………………………
Postal Address: ………………………………………………..……………………………………………...
Suburb: …………………………………………………………….. Postcode: …………………………….
Phone(home):…………………..……. Phone(work):………..…………... Fax: ……………….…………
Mobile: ………………………….…..… Email: ……………..……………………………………………….
2.0 DEVELOPMENT APPLICATION / CONSTRUCTION DETAILS
Is this related to a Development Application?
☐Yes / If these works are in conjunction with an active Development Application Approval please complete Section 2: (Mandatory where applicable).☐No / Please leave Section 2 blank and continue to Section 3.
Property Address:……………………………………………………………………………………………
DA / CD No: ………………………………………………………………………………………………….
PRIVATE CERTIFIERS DETAILS (if applicable)
Certifier: …………………………………………………….………………………………………………….
Phone: …………………...… Fax: ………..………………….. Mobile: ………..……………………..……
Email: …………………………………………………………………………………………………………..
Note: Failure to include any Mandatory details may result in delay to the processing of your application and/or refusal.
3.0 APPLICATION FOR PERMIT: (Please tick the following boxes as appropriate)
(Application Fees Apply – Additional Permit Fees may also apply)
☐ Road Opening Permit (Refer to 7.1) ☐ Hoarding (Refer to 7.5)
☐ Work Zone Permit (Refer to 7.2) ☐ Connect to Stormwater System (Refer to 7.6)
☐ Temporary Road Closure (Refer to 7.3) ☐ Construction Permit (Construction of Vehicle
☐ Vehicular Crossing – Assessment (Refer to 7.4) Crossing / Footpath / K&G) (Refer to 7.7)
4.0 SITE LOCATION DETAILS
Street: …………………………………………………………………………………………………...……..
Between: …………………………………….………and …………….……………………..………...…….
Suburb: …………………………………………………………………..…………………………………….
Requested Dates: …………………….…………..… to ……………..…….……………………………..
Requested Times: …………………….…………..… to ………………..…………………………………..
Estimated Value of Works: $ ……………………………………………………………………….………..
Details of Works (Description of Works): …………………………………………………......
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
Please attach a sketch/drawing of proposed works to this application indicating the work area and defining the Scope of Works.
5.0 PUBLIC LIABILITY
Has a copy of a current Public Liability Insurance valued up to $20 million been attached?
☐Yes / Proceed to Section 6.☐No / Please obtain a copy of a current Public Liability Insurance valued up to $20 million prior to lodging your application form.
6.0 WORK AREA
Does the works require: (Please tick the following boxes as appropriate)
The opening of or partial/full closure of a footpath? / ☐Yes ☐NoThe opening of or partial/full closure of a road? / ☐Yes ☐No
Plant (concrete trucks etc.) to be parked on the roadway and/or nature strip? / ☐Yes ☐No
The storage of equipment, materials or furniture on the roadway, footpath and/or nature strip? / ☐Yes ☐No
Note: If you answered Yes to any of the above, a Traffic Control Plan is required to be submitted with this application. The Traffic Control Plan must be in accordance with AS 1742.3 – 2009 illustrating site area and position of plant, all signage and traffic control devices that are to be used.
Has a Traffic Control Plan been attached?
☐Yes / Proceed to Section 7☐No / Please obtain a Traffic Control Plan prior to lodging your application form
7.0 WORK SPECIFICATIONS
Please fill in the required sections for your required permit(s).
Does this work require the opening of a footpath, nature strip or roadway (notrelated to a vehicular crossing application) If NO, then go to section 7.2 ☐Yes ☐No
Is this Emergency Works? Verbal Approval by Council Officer to be required. ☐Yes ☐No
Please attach a site plan/sketch ☐ Construction Drawing (If available) ☐Kerb Alignment
showing the proposed works ☐Footpath Alignment ☐Include Dimensions
in relation to the following: ☐ Work Area ☐Material Identified
☐ Boundary Lines
Dial Before You Dig Reference Number & Date Lodged :……………………………………..………….
For Estimation Purposes ONLY:
Asset Type / Admin
Use Only / Material & Dimensions of Opening* / Rate** / Sub - Total
Roadway / Code 135 / m² / $ / $
Footpath / Code 135 / m² / $ / $
Kerb & Gutter / Code 135 / m² / $ / $
Driveway / Code 135 / m² / $ / $
Nature Strip / Code 135 / m² / $ / $
Total Estimated Cost of Restoration: / $
· * Please refer to the “Works On Council’s Road Reserve Assets Policy” for Calculation of Areas
for Restoration Charges
· ** Please refer to Burwood Council’s “Statement of Revenue Policy incorporating Schedule of
Fees & Charges” to determine restoration rate
A bond is payable for all Road Opening Permits once the application is approved. Please complete section 8.0 for the Bond applicant’s details
7.2 Application for Work Zone Permit
Application Fee (non-refundable) $ 130.00 (Code 351)
Council supplied, erected and removed signs $ 620.00
Per linear meter per day (outside of Town Centre) $ 5.30
Per linear meter per day (inside of Town Centre) $ 8.50
An additional fee of 80% of current Parking Rate is applicable for a Work Zone located in a Ticket Parking area.
Work Zone Length…………………………………….Street Name:………………………...……………..
Commencement Date: ………………………………Duration (No. of Weeks):………………………….
Please Note: Work Zone applications which propose significant changes to parking and traffic may require approval of the Burwood Local Traffic Committee and Council, which may require 6 weeks for approval to be granted. Please read the Works Zone Policy for full requirements of the activity.
7.3 Application for Temporary Road Closure Including Standing Plant Permit
Application Fee (non-refundable) $ 126.00 (Code 352)
Partial Footpath (minimum 1 week) $ 24.00 per m² per weekStanding Plant $ 315.00 per item
Road closure $ 8.50 per metre per day per lane.
Road closure in a parking metered area, an additional fee of 80% of current Parking Rate is applicable.
☐Burwood Police approval attached ☐RMS accredited Traffic Control Plan attached
☐Road occupancy license from RMS attached ☐RMS accredited Traffic Controllers to be
used to implement the Traffic Control Plan?
No. of Lane Closure: …………Length of Road Closure…………..Footpath Closure (m²)……………
Street Name: …………………..Commencement Date: ……...... Duration (Days)…..………………
Please read the Temporary Road Closure (including Standing Plant) Policy for full requirements of the activity.
Does this work require an assessment/ approval for a new
Vehicular Crossing or on an existing Vehicular Crossing? ☐Yes ☐No
Does your existing driveway scrape? ☐Yes ☐ No
Does your vehicle have a lowered or modified profile? (Design fees may
apply for non-standard crossing designs) ☐Yes ☐No
Is the house setback distance less than 5.5 metres? ☐Yes ☐No
Is a Council tree located within 2.0m of the proposed crossing? ☐Yes ☐No
Will the proposed crossing provide an additional vehicular crossing
for the property? ☐Yes ☐No
Are any public utility service boxes or poles in the location of the proposed
crossing? ☐Yes ☐No
Are any Council drainage pits or other obstructions in the location of the
proposed crossing? ☐Yes ☐No
Is the proposed crossing within 6.0m of an intersection? ☐Yes ☐No
Would you like to receive a quote for the work to be constructed by Council? ☐Yes ☐No
Is work to be constructed by Contractor/s? If yes, go to Section 7.7 ☐Yes ☐No
Please read the Council’s Works on Council’s Road Reserve Assets Policy for full requirements of the activity.
Does this work require a Hoarding Permit? If NO, then go to Section 7.6 ☐Yes ☐No
What type of hoarding is required? ☐Type A
☐Type B
Has a site plan (scale no less than 1:100) including dimensions been attached? ☐Yes ☐No
Please read the Hoardings Information Sheet for full requirements of the activity.
Does this work relate to the repair or replacement of an existing
stormwater outlet pipe? If YES complete Section 7.1 Application for
Road Opening Permit. ☐Yes ☐No
Does this work require a Connect to Storm Water System
Permit? If NO, then go to Section 7.7. ☐Yes ☐No
Are you connecting from your roof water to the kerb?(New connections only.) ☐Yes ☐No
If no, is this a storm water line connecting to Council’s storm water structure? ☐Yes ☐No
If yes, a certified storm water drainage plan is required. ☐Yes ☐No
Please read the Council’s Works on Council’s Road Reserve Assets Policy for full requirements of the activity. http://www.burwood.nsw.gov.au/roads - policies.html.
7.7 Application for Construction Permit (Vehicular Crossing /Footpath /Kerb & Gutter etc.)
Application Fee (Administration) $122.50 (Code 70)Compliance Inspection Fees (During Construction) $314.00 (Code 322)
Damage Control Inspection (For DA /CD Only) $111.00 (Code T70)
(Application Fees are Non-Refundable. Inspection Fees paid upon arrival)
Does this work require a permit for other construction related works not covered
above on Council Property (Vehicle Crossing / Footpath / K&G / Nature Strip)? ☐Yes ☐No
Are you completing a vehicular crossing using your own contractor? ☐Yes ☐No
Would you like to receive a quote for the work to be constructed by Council? ☐Yes ☐No
Please attach a site plan/sketch ☐ Construction Drawing (If available) ☐ Kerb Alignmentshowing the proposed works ☐Footpath Alignment ☐Include Dimensions
in relation to the following: ☐ Work Area ☐Material Identified
☐ Boundary Lines
Dial Before You Dig Reference Number & Date Lodged :………………………………………...………….
Trim No: 15/26255 Page 1 of 7
Works on Council’s Property – Application Form – 2015-2016
Trim No: 15/26255 Page 1 of 7
Works on Council’s Property – Application Form – 2015-2016
8 BOND REFUND INFORMATION (for Road Opening Permits)
Name: …………………………………………………………………………………………………………..
Company Name: ………………………………………………………………………………………………
Postal Address: ………………………………………………..……………………………………………...
Suburb: …………………………………………………………….. Postcode: …………………………….
Phone(home):…………………..……. Phone(work):………..…………... Fax: ……………….…………
Mobile: ………………………….…..… Email: ……………..……………………………………………….
9 CONTRACTOR DETAILS (if Different from Applicant’s Details)
Company Name: ……………………………………………………………………………………………..
Postal Address: …………………………………...………………….. Postcode: ……………………….
Phone: ……………………………………...….. Fax: ………………………………………………………
Mobile: ………………………...………………. Email: …………………………………………………….
Please include the contractor details where applicable and/or if different from applicant details.
10 PRIVACY STATEMENT
If you are applying for consent as an individual, you may be providing Council with personal information (such as your name and address) within the meaning of the Privacy and Personal Information Protection Act 1998. You are obliged by law to provide your name and address. If you do not provide the personal information requested Council may be unable to process your application.
Council is collecting this personal information from you in order to identify and process your application. You may make application for access or amendment to information held by Council. You may also make a request that Council suppress your personal information from being made publicly available. Council will consider any such application in accordance with the relevant legislation.
Enquiries concerning this matter can be addressed to Council’s Public Officer.
11 LODGEMENT INFORMATION
Method of Lodgement
It is recommended that applications be submitted in person, to avoid time lost in the event of incomplete applications and the need to return them by post.
Applications that are lodged by post should be addressed to the General Manager at PO Box 240 Burwood NSW 1805.
Fees
Your application will be assessed based on the information provided in this application. Additional fees and charges apply upon successful application of the above requested permits. Council Officers will assess and reply advising of any information required and/or additional fees.
All fees associated with the above activities are available on Council’s website at www.burwood.nsw.gov.au.
Further Information
For further assistance, contact Council on 9911 9911 between 8.30am and 4.30pm Monday-Friday.
12 CHECKLIST REVIEW OF INFORMATION REQUIRED
To ensure a quick review of an application, the following section must be completed:
Section 1 / All partsSection 2 / All parts if related to an active Development Application approval
Section 3 / Tick the relevant box or boxes if more than one activity applies
Section 4 / All parts inclusive of an attachment of a drawing/sketch of the proposed works
Section 5 / All parts
Section 6 / All parts
Section 7 / This contains brief information on each activity applicable to this application. The applicant must review and follow the relevant policies for the activity to ensure that all requirements are known and complied
Section 8 / All parts (where bond has been held)
Section 9 / All parts (if different from applicants details)
Section 10 / Information requirements
Section 11 / Information requirements
Section 13 / Completion of the declaration
13 DECLARATION
I certify that I have read and understood the Works on Council Property Policy and all its conditions.
Signed: …………………………………………………………………. Date: ……………………………...
OFFICE USE ONLY
Receipt No:…………………………… Date: ………………………… Amount $......
Staff Name: ……………………………………………………………………………………………………
Payment may be made by cash, cheque or credit card (Mastercard and Visa accepted)
Trim No: 15/26255 Page 1 of 7
Works on Council’s Property – Application Form – 2015-2016