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
Trust Partnership Company Private Person(s)
Trust or Company Name (if applicable):
Full Names:
Application is made for a:
Land Use Consent Subdivision Consent
I/we opt out/do not opt out (delete one) of the fast-track consent process (only applies to controlled activities
under the District Plan, where an electronic address for service is provided)
Brief description of the proposed activity:
Have you applied for a Building Consent? Yes, Building Consent Number
Site location/description
Street Address of Site:
Legal Description:
Certificate of Title:
Application Form
Resource Consent
29 Bowler Avenue, Gore 9710
PO Box 8, Gore 9740
Phone 03 209 0330
Application Form Resource Consent
Contact Details
Name: (applicant/agent)
Address: Postcode:
Email: Phone (daytime):
Address for Invoices or Refunds
Bank Details for Refunds
Bank Account Name:
Bank Account Number:
Ownership of the Site
Who is the current owner of the site?
If the applicant is not the site owner, please provide the site owner’s contact details:
Address: Postcode:
Email: Phone (daytime):
Occupation of the Site
Please list the full name and address of each occupier of the site if this is not the applicant:
Monitoring of your Resource Consent
Depending on the type of activity for which consent is sought it may be necessary for the Council to undertake
monitoring to ensure compliance with any conditions of consent. To assist with setting a date for monitoring,
please estimate the date of completion of the work for which Resource Consent is required.
(month and year)
Monitoring is an additional cost over and above consent processing. You may be charged at the time of the
consent being issued or at the time monitoring occurs. Please refer to the Councils Schedule of Fees for the
current monitoring fee.
Application Form Resource Consent 2
Application Form Resource Consent 3
Detailed Description of Proposed Activity
Please describe the proposed activity for the site, giving as much detail as possible. Where relevant, discuss
the bulk and location of buildings, parking provision, traffic movements, manoeuvring, noise generation,
signage, hours of operation, number of people on-site, number of visitors etc. Please provide proposed site
plans and elevations.
Description of Site and Existing Activity
Please describe the existing site, its size, location, orientation and slope. Describe the current usage and
type of activity being carried out on the site. Where relevant, discuss the bulk and location of buildings,
parking provision, traffic movements, manoeuvring, noise generation, signage, hours of operation, number
of people on-site, number of visitors etc. Please also provide plans of the existing site and buildings.
Photographs may help.
(Attach separate sheets if necessary)
District Plan Zoning
What is the District Plan zoning of the site?
List any overlaying District Plan requirements that apply to the site e.g. designations, subject to inundation,
contaminated land, river margin, landscape area, in a landscape management area, in a townscape or
heritage precinct, scheduled buildings on-site etc? If unsure, please check with Council Planning staff.
Application Form for a Resource Consent 4
Breaches of District Plan Rules
Please detail the rules that will be breached by the proposed activity on the site (if any). Also detail the
degree of those breaches.
Affected Persons’ Approvals
I/We have obtained the written approval of the following people/organisations and they have signed the plans
of the proposal:
PLEASE NOTE: You must submit the completed written approval form(s), and any plans signed by affected
persons, with this application. If a written approval is required, but not obtained from an affected person, it is
likely that the application will be fully notified or limited notified.
Assessment of Effects on Environment (AEE)
In this section you need to consider what effects your proposal will have on the environment. You should
discuss all actual and potential effects on the environment arising from this proposal. The amount of detail
provided must reflect the nature and scale of the development and its likely effect. i.e. small effect equals
small assessment.
The following additional Resource Consents from Environment Southland are required and have/have not
(delete one) been applied for:
Water Permit Discharge Permit Land Use Consent for certain uses of lake beds and rivers
Not applicable
I certify that, to the best of my knowledge and belief, the information given in this application is true and
I accept that I have a legal obligation to comply with any conditions imposed on the Resource Consent should
this application be approved.
Subject to my/our rights under section 357B and 358 of the RMA to object to any costs, I agree to pay all
the fees and charges levied by the Gore District Council for processing this application, including a further
account if the cost of processing the application exceeds the deposit paid.
Signature of Applicant/Agent (delete one): Date:
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
What happens when further information is required?
If an application is not in the required form, or does not include adequate information, the Council may
reject the application, pursuant to section 88 of the RMA. In addition (section 92 RMA) the Council can
request further information from an applicant at any stage through the process where it may help to a better
understanding of the nature of the activity, the effects it may have on the environment, or the ways in which
adverse effects may be mitigated. The more complete the information provided with the application, the less
costly and more quickly a decision will be reached.
Application Form Resource Consent 5
The 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
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.
Application Form Resource Consent 6
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