Fillable APPLICATION FOR CHANGE OR CANCELLATION OF A RESOURCE (Queenstown Lakes District Council New Zealand)

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APPLICATION FOR CHANGE OR CANCELLATION OF A RESOURCE (Queenstown Lakes District Council New Zealand)

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Page 1/8 // January 2019
FORM 10:
APPLICATION FOR CHANGE OR CANCELLATION
OF A RESOURCE CONSENT CONDITION
Under section 127 of the Resource Management Act 1991 (Variation)
PLEASE COMPLETE ALL MANDATORY FIELDS* OF THIS FORM.
This form provides contact information and details of your application. If your form does not provide the required information it will be returned
to you to complete. Until we receive a completed form and payment of the initial fee, your application may not be accepted for processing.
APPLICANT //
CORRESPONDENCE DETAILS //
If you are acting on behalf of the applicant e.g. agent, consultant or architect
please ll in your details in this section.
Name & Company:
Phone Numbers: Day Mobile:
Email Address:
Postal Address:
Postcode:
Our preferred methods of corresponding with you are by email and phone.
The decision will be sent to the Correspondence Details by email unless requested otherwise.
• Must be a person or legal entity (limited liability company or trust).
• Full names of all trustees required.
• The applicant name(s) will be the consent holder(s) responsible for the consent and any associated costs.
*Applicant’s Full Name / Company / Trust:
(Name Decision is to be issued in)
All trustee names (if applicable):
Contact Name if Company or Trust:
*Postal Address: *Post code:
*Contact details supplied must be for the applicant and not for an agent acting on their behalf and must include a valid postal address
*Email Address:
*Phone Numbers: Day Mobile:
The Applicant is:
Owner Prospective Purchaser (of the site to which the application relates)
Occupier Lessee Other - Please Specify
*Attention:
*Postal Address: *Post code:
Please provide an email AND full postal address.
*Email:
Applicant: Agent: Other, please specify:
Email: Post:
INVOICING DETAILS //
Invoices will be made out to the applicant but can be sent to another party if paying on the applicant’s behalf.
For more information regarding payment please refer to the Fees Information section of this form.
Please select a preference for who should receive any invoices and how they would like to receive them.
PREAPPLICATION MEETING OR URBAN DESIGN PANEL
Have you had a pre-application meeting with QLDC or attended the urban design panel regarding this proposal?
Yes No Copy of minutes attached
If ‘yes’, provide the reference number and/or name of sta member involved:
Page 2/8 // January 2019
*Attention:
*Email:
Details are the same as above
Applicant: Landowner: Other, please specify:
DETAILS OF SITE // Legal description eld must list legal descriptions for all sites pertaining to the application.
Any elds stating ‘refer AEE’ will result in return of the form to be fully completed.
Address / Location to which this application relates:
Legal Description:
Can be found on the Computer Freehold Register or Rates Notice – e.g Lot x DPxxx (or valuation number)
District Plan Zone(s):
SITE VISIT REQUIREMENTS //
Is there a gate or security system restricting access by council?
Is there a dog on the property?
Are there any other hazards or entry restrictions that council sta need to be aware of?
If ‘yes’ please provide information below
YES NO
YES NO
YES NO
DETAILS OF SITE // Legal description eld must list legal descriptions for all sites pertaining to the application.
Any elds stating ‘refer AEE’ will result in return of the form to be fully completed.
Address / Location to which this application relates:
Legal Description:
Can be found on the Computer Freehold Register or Rates Notice – e.g Lot x DPxxx (or valuation number)
SITE VISIT REQUIREMENTS // Should a Council officer need to undertake a site visit please answer the
questions below
Is there a gate or security system restricting access by council?
Is there a dog on the property?
Are there any other hazards or entry restrictions that council sta need to be aware of?
If ‘yes’ please provide information below
YES NO
YES NO
YES NO
Click here for further information and our estimate request form
DEVELOPMENT CONTRIBUTIONS INVOICING DETAILS //
If it is assessed that your consent requires development contributions any invoices and correspondence relating to these will be sent via email. Invoices will
be sent to the email address provided above unless an alternative address is provided below. Invoices will be made out to the applicant/owner but can be
sent to another party if paying on the applicant’s behalf.
For more information please see appendix 2 at the end of this form.
Please select a preference for who should receive any invoices.
OWNER DETAILS // Please supply owner details for the subject site/property if not already indicated above
Owner Name:
Owner Address:
If the property has recently changed ownership please indicate on what date (approximately) AND the names of the previous owners:
Date:
Names:
RESOURCE CONSENT TO BE VARIED
OTHER CONSENTS
Is consent required under a National Environmental Standard (NES)?
NES for Assessing and Managing Contaminants in Soil to Protect Human Health 2012
An applicant is required to address the NES in regard to past use of the land which could contaminate soil
to a level that poses a risk to human health. Information regarding the NES is available on the website
http://www.mfe.govt.nz/laws/standards/contaminants-in-soil/.
You can address the NES in your application AEE OR by selecting ONE of the following:
This application does not involve subdivision (excluding production land), change of use or
removal of (part of) a fuel storage system. Any earthworks will meet section 8(3) of the NES
(including volume not exceeding 25m
3
per 500m
2
). Therefore the NES does not apply.
I have undertaken a comprehensive review of District and Regional Council records and I
have found no record suggesting an activity on the HAIL has taken place on the piece of land
which is subject to this application.
NOTE: depending on the scale and nature of your proposal you may be required to provide
details of the records reviewed and the details found.
I have included a Preliminary Site Investigation undertaken by a Suitably Qualied Person.
An activity listed on the HAIL has more likely than not taken place on the piece of land which is subject to
this application. I have addressed the NES requirements in the Assessment of Environmental Eects.
Any other National Environmental Standard
Yes N/A
Are any additional consent(s) required that have been applied for separately?
Otago Regional Council
Consents required from the Regional Council (note if have/have not been applied for):
Yes N/A
CONDITIONS TO BE CHANGED OR CANCELLED
My application relates to the following specic condition(s) of the resource consent:
Detail the proposed change / cancellation including reasons for change and proposed replacement condition wording:
My application relates to the following resource consent(s): RM
To: briey describe the resource consent and subject site
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 3/8 // January 2019
INFORMATION REQUIRED TO BE SUBMITTED //
PRIVACY INFORMATION
FEES INFORMATION
Attach to this form any information required
(see below & appendix 1).
To be accepted for processing, your application should include the following:
Computer Freehold Register for the property (no more than 3 months old)
and copies of any consent notices and covenants
(Can be obtained from Land Information NZ at https://www.linz.govt.nz/).
A plan or map showing the locality of the site, topographical features, buildings etc.
A site plan at a convenient scale.
Written approval of every person who may be adversely aected by the change/cancellation.
An Assessment of the Eects of the Change/Cancellation (AEE).
A
n AEE is a written document outlining how the potential eects of the change/cancellation have been considered.
Address the changes in the context of what has been approved and the District Plan, and identify if any parties will
be aected, including specically persons who gave their approval, or submitted on, the resource consent to be
changed/cancelled.
We prefer to receive applications electronically – see Appendix 3 – Naming of Documents Guide
Please ensure documents are scanned at a minimum resolution of 300 dpi.
Each document should be no greater than 10mb
The information you have provided on this form is required so that your application can be processed under the Resource
Management Act 1991 and may also be used in statistics collected and provided to the Ministry for the Environment and
Queenstown-Lakes District Council. The information will be stored on a public register and may be made available to the
public on request or on the company’s or the Council’s websites.
Section 36 of the Resource Management Act 1991 deals with administrative charges and allows a local authority to levy
charges that relate to, but are not limited to, carrying out its functions in relation to receiving, processing and granting of
resource consents (including certicates of compliance and existing use certicates).
Invoiced sums are payable by the 20th of the month after the work was undertaken. If unpaid, the processing of an
application, provision of a service, or performance of a function will be suspended until the sum is paid. You may also be
required to make an additional payment, or bring the account up to date, prior to milestones such as notication, setting
a hearing date or releasing the decision. In particular, all charges related to processing of a resource consent application
are payable prior to issuing of the decision. Payment is due on the 20th of the month or prior to the issue date –
whichever is earlier.
If your application is notied or requires a hearing you will be requested to pay a notication deposit and/or a hearing
deposit. An applicant may not oset any invoiced processing charges against such payments.
Section 357B of the Resource Management Act provides a right of objection in respect of additional charges. An objection
must be in writing and must be lodged within 15 working days of notication of the decision.
LIABILITY FOR PAYMENT – Please note that by signing and lodging this application form you are acknowledging that
the Applicant is responsible for payment of invoices and in addition will be liable to pay all costs and expenses of debt
recovery and/or legal costs incurred by QLDC related to the enforcement of any debt.
MONITORING FEES – Please also note that if this application is approved you will be required to meet the costs of
monitoring any conditions applying to the consent, pursuant to Section 35 of the Resource Management Act 1991.
DEVELOPMENT CONTRIBUTIONS – Your development, if granted, may also incur development contributions under the
Local Government Act 2002. You will be liable for payment of any such contributions.
A list of Consent Charges is available on the on the Resource Consent Application Forms section of the QLDC website. If
you are unsure of the amount to pay,
please call 03 441 0499 and ask to speak to our duty planner.
If the initial fee charged is insucient to cover the actual and reasonable costs of work undertaken on the application
you will be required to pay any additional amounts and will be invoiced monthly as work on the application continues.
Please note that if the Applicant has outstanding fees owing to Council in respect of other applications, Council may
choose to apply the initial fee to any outstanding balances in which case the initial fee for processing this application
may be deemed not to have been paid.
Please ensure to reference any banking payments correctly. Incorrectly referenced payments may cause delays to the
processing of your application whilst payment is identied.
Page 4/8 // January 2019
PAYMENT // An initial fee must be paid prior to or at the time of the application and proof of payment submitted.
Please note processing will not begin until payment is received (or identied if incorrectly referenced).
I conrm payment by:
Bank transfer to account 02 0948 0002000 000 (If paying from overseas swiftcode is – BKNZNZ22)
Cheque payable to Queenstown Lakes District Council attached
Manual Payment at reception (can only be accepted once application has been lodged and
acknowledgement email received with your unique RM reference number)
*Reference
*Amount Paid
(For required initial fees refer to website for Resource Consent Charges or speak to the Duty Planner by phoning 03 441 0499)
*Date of Payment
Please reference your payments as follows:
Applications yet to be submitted: RM followed by rst 5 letters of applicant name e.g RMJONES
Applications already submitted: Please use the RM# reference that has been assigned to your application, this will have been
emailed to yourself or your agent.
APPLICATION & DECLARATION
The Council relies on the information contained in this application being complete and accurate. The Applicant must take all reasonable
steps to ensure that it is complete and accurate and accepts responsibility for information in this application being so.
If lodging this application as the Applicant:
I/we hereby represent and warrant that I am/we are aware of all of my/our obligations
arising under this application including, in particular but without limitation, my/our
obligation to pay all fees and administrative charges (including debt recovery and legal
expenses) payable under this application as referred to within the Fees Information section.
If lodging this application as agent of the Applicant:
I/we hereby represent and warrant that I am/we are authorised to act as agent of the Applicant in
respect of the completion and lodging of this application and that the Applicant is aware of all of
his/her/its obligations arising under this application including, in particular but without limitation,
his/her/its obligation to pay all fees and administrative charges (including debt recovery and legal
expenses) payable under this application as referred to within the Fees Information section.
I hereby apply for the resource consent(s) for the Proposal described above and I certify that, to the best of my
knowledge and belief, the information given in this application is complete and accurate.
Signed (by or as authorised agent of the Applicant) **
Full name of person lodging this form
Firm/Company Dated
**If this form is being completed on-line you will not be able, or required, to sign this form and the on-line lodgement will be treated as
conrmation of your acknowledgement and acceptance of the above responsibilities and liabilities and that you have made the above
representations, warranties and certication.
OR:
PLEASE TICK
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 5/8 // January 2019
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APPENDIX 1 // RMA requirements for an application for Resource Consent
Section 2 of the District Plan provides additional information on the information that should be submitted with a land use or
subdivision consent.
The RMA (Fourth Schedule to the Act) requires the following:
1 INFORMATION MUST BE SPECIFIED IN SUFFICIENT DETAIL
• Any information required by this schedule, including an assessment under clause 2(1)(f) or (g), must be specied
in sucient detail to satisfy the purpose for which it is required.
2 INFORMATION REQUIRED IN ALL APPLICATIONS
• (1) An application for a resource consent for an activity (the activity) must include the following:
• (a) a description of the activity:
• (b) a description of the site at which the activity is to occur:
• (c) the full name and address of each owner or occupier of the site:
• (d) a description of any other activities that are part of the proposal to
which the application relates:
• (e) a description of any other resource consents required for the proposal
to which the application relates:
• (f) an assessment of the activity against the matters set out in Part 2:
• (g) an assessment of the activity against any relevant provisions of a
document referred to in section 104(1)(b).
(2) The assessment under subclause (1)(g) must include an assessment of the activity against—
• (a) any relevant objectives, policies, or rules in a document; and
• (b) any relevant requirements, conditions, or permissions in any
rules in a document; and
• (c) any other relevant requirements in a document (for example,
in a national environmental standard or other regulations).
(3) An application must also include an assessment of the activity’s eects on the environment that—
• (a) includes the information required by clause 6; and
• (b) addresses the matters specied in clause 7; and
• (c) includes such detail as corresponds with the scale and signicance
of the eects that the activity may have on the environment.
ADDITIONAL INFORMATION REQUIRED IN SOME APPLICATIONS
• An application must also include any of the following that apply:
• (a) if any permitted activity is part of the proposal to which the application relates, a description of the
permitted activity that demonstrates that it complies with the requirements, conditions, and
permissions for the permitted activity (so that a resource consent is not required for that activity
under section 87A(1)):
• (b) if the application is aected by section 124 or 165ZH(1)(c) (which relate to existing resource
consents), an assessment of the value of the investment of the existing consent holder (for the
purposes of section 104(2A)):
Information
provided
within the
Form above
Include in
an attached
Assessment
of Eects
(see Clauses
6 & 7 below)
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 6/8 // January 2019
ASSESSMENT OF ENVIRONMENTAL EFFECTS
Clause 6: Information required in assessment of environmental eects
• (1) An assessment of the activity’s eects on the environment must include the following information:
• (a) if it is likely that the activity will result in any signicant adverse eect on the environment,
a description of any possible alternative locations or methods for undertaking the activity:
• (b) an assessment of the actual or potential eect on the environment of the activity:
• (c) if the activity includes the use of hazardous substances and installations, an assessment of
any risks to the environment that are likely to arise from such use:
• (d) if the activity includes the discharge of any contaminant, a description of—
• (i) the nature of the discharge and the sensitivity of the receiving environment to
adverse eects; and
• (ii) any possible alternative methods of discharge, including discharge into any
other receiving environment:
• (e) a description of the mitigation measures (including safeguards and contingency plans where
relevant) to be undertaken to help prevent or reduce the actual or potential eect:
• (f) identication of the persons aected by the activity, any consultation undertaken, and any
response to the views of any person consulted:
• (g) if the scale and signicance of the activity’s eects are such that monitoring is required, a
description of how and by whom the eects will be monitored if the activity is approved:
• (h) if the activity will, or is likely to, have adverse eects that are more than minor on the exercise
of a protected customary right, a description of possible alternative locations or methods for the
exercise of the activity (unless written approval for the activity is given by the protected customary
rights group).
(2) A requirement to include information in the assessment of environmental eects is subject to the provisions
of any policy statement or plan.
(3) To avoid doubt, subclause (1)(f) obliges an applicant to report as to the persons identied as being aected
by the proposal, but does not—
• (a) oblige the applicant to consult any person; or
• (b) create any ground for expecting that the applicant will consult any person.
CLAUSE 7: MATTERS THAT MUST BE ADDRESSED BY ASSESSMENT OF ENVIRONMENTAL EFFECTS
• (1) An assessment of the activity’s eects on the environment must address the following matters:
• (a) any eect on those in the neighbourhood and, where relevant, the wider community, including
any social, economic, or cultural eects:
• (b) any physical eect on the locality, including any landscape and visual eects:
• (c) any eect on ecosystems, including eects on plants or animals and any physical disturbance of
habitats in the vicinity:
• (d) any eect on natural and physical resources having aesthetic, recreational, scientic, historical,
spiritual, or cultural value, or other special value, for present or future generations:
• (e) any discharge of contaminants into the environment, including any unreasonable emission of
noise, and options for the treatment and disposal of contaminants:
• (f) any risk to the neighbourhood, the wider community, or the environment through natural hazards
or the use of hazardous substances or hazardous installations.
(2) The requirement to address a matter in the assessment of environmental eects is subject to the provisions
of any policy statement or plan.
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 7/8 // January 2019
APPENDIX 3 // Naming of documents guide
While it is not essential that your documents are named the following, it would be helpful if you could title your documents
for us. You may have documents that do not t these names; therefore below is a guide of some of the documents we
receive for resource consents. Please use a generic name indicating the type of document.
Application Form 10
Assessment of Environmental Eects (AEE)
Computer Register (CFR)
Covenants & Consent Notice
Aected Party Approval/s
Landscape Report
Engineering Report
Geotechnical Report
Trac Report
Urban Design Report
Will your resource consent result in a Development Contribution and what is it?
• A Development Contribution can be triggered by the granting of a resource consent and is a nancial charge levied on
new developments. It is assessed and collected under the Local Government Act 2002. It is intended to ensure that
any party, who creates additional demand on Council infrastructure, contributes to the extra cost that they impose on
the community. These contributions are related to the provision of the following council services:
• Water supply
• Wastewater supply
• Stormwater supply
• Reserves, Reserve Improvements and Community Facilities
• Transportation (also known as Roading)
Click here for more information on development contributions and their charges
OR Submit an Estimate request *please note administration charges will apply
Development
Contribution
Estimate Request
Form
APPENDIX 2 // Development Contributions
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 8/8 // January 2019
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APPLICATION FOR CHANGE OR CANCELLATION OF A RESOURCE (Queenstown Lakes District Council New Zealand)

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Completed 10 November 2020

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