Application Form
Deemed Permitted Marginal
or Temporary Activity
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Application Form Deemed Permitted Marginal or Temporary Activity
The full legal name of Applicant(s) are required. For Trusts, Estates and Partnerships, the name of the Trust,
Estate or Partnership must be given and the full legal names of all trustees, executors or partners
are required.
Trust Partnership Company Private Person(s)
Trust or Company Name (if applicable):
Full Names:
Have you applied for a Building Consent? Yes, Building Consent Number
Site Location/Description
I am/We are the: owner occupier lessee prospective purchaser of the site (tick one)
Street Address of Site:
Legal Description:
Certificate of Title:
Contact Details
Address: Postcode:
Email: Phone (daytime):
Address for Invoices or Refunds (if different from above)
Address: Postcode:
Bank Details for Refunds
Bank Account Name:
Bank Account Number:
Ownership of the Site
Full name and address of each owner and occupier of the application site:
Site Plan
I have provided plan(s) to scale showing the site at which the activity is to occur, showing the height,
shape, and location on the site of the proposed activity.
Activity Description
Description of the proposed activity:
Rule Breach Assessment
List the rules being breached and describe how the rules breaches will be marginal or temporary:
Application Form Deemed Permitted Marginal or Temporary Activity 2
Application Form Deemed Permitted Marginal or Temporary Activity 3
Permitted Activity Comparison
Compare the proposed activity to a permitted activity, and discuss whether the adverse effects are no
different in character, intensity and scale:
Affected person assessment
Identify whether any person will be adversely affected by the activity, and discuss whether these adverse
effects are less than minor:
Privacy – Local Government Official Information and Meetings Act 1987
You should be aware that this document becomes a public record once submitted. Under the above Act,
anyone can request to see copies of applications lodged with the Council. The Council is obliged to make
available the information requested unless there are grounds under the above Act that justify withholding it.
While you may request that it be withheld, the Council will make a decision following consultation with you. If
the Council decides to withhold an application, or part of it, that decision can be reviewed by the Office of the
Please advise if you consider it necessary to withhold your application, or parts of it, from any persons
(including the media) to (tick those that apply):
Avoid unreasonably prejudicing your commercial position
Protect information you have supplied to the Council in confidence
Avoid serious offence to tikanga Maori or disclosing location of waahi tapu
Application Form Deemed Permitted Marginal or Temporary Activity 4
Council recovers all actual and reasonable costs of processing your application. Most applications require
a deposit and costs above this deposit will be recovered. A current fees schedule is available on or from Planning staff.
Further Assistance
Please discuss your proposal with us if you require any further help with preparing your application.
The Council does provide pre-application meetings without charge to assist in understanding the issues
associated with your proposal and completing your application. This service is there to help you.
Please note that we are able to provide you with planning information but we cannot prepare the application
for you. You may need to discuss your application with an expert such as a planning consultant, surveyor or
lawyer, if you need further advice.
Gore District Council Planning Services staff can be contacted as follows:
In Writing: Gore District Council, PO Box 8, Gore 9740
In Person: Gore District Council, 29 Bowler Avenue, Gore,
but please phone first to make an appointment.
By Phone: (03) 209 0330
By Email:
There is also information on our website at
Information Requirements
Completed and Signed Application Form
Description of Activity and Assessment of Effects
Site Plan, Floor Plan and Elevations (where relevant)
Historic Copy of Certificate of Title (less than 3 months old) including any relevant restrictions
(such as consent notices, covenants, encumbrances, building line restrictions)
Written Approval forms and plans signed and dated by Affected Persons
Application Fee (cash, cheque, Internet banking or EFTPOS only; no Credit Cards accepted)
Bank account details for refunds
In addition, subdivision applications also need the following information
Number of existing lots Number of proposed lots
Total area of subdivision The position of all new boundaries
Payment Method
Cash (do not post)
EFTPOS (at Gore District Council)
Internet banking
Cheques payable to: Gore District Council
Post cheques to: Gore District Council
PO Box 8, Gore 9740
Internet Banking Payments: Gore District Council
Account Number: 03-0915-0289519-00
Particulars: Please use your Name
Reference: Please use your Address
In order to ensure your application is not rejected or delayed through requests for further information,
please make sure you have included all of the necessary information.
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