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APPLICATION FOR RESOURCE MANAGEMENT CONSENT

SECTION 88 OF THE RESOURCE MANAGEMENT ACT 1991

1.1 Full Name of Applicant:

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1.2 Postal Address of Applicant:

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1.3 Applicant is the (e.g. Owner, Lessee etc) of the property:

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1.4 Name and Address of Owner:

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1.5 Name and Address of Occupier:

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1.6 Location to which this Application relates is (Address and Legal Description) :

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2.0 Please circle one of the following activities in which this consent relates to:

Controlled Activity

Discretionary Activity

Non-Complying Activity

Subdivision Consent

PO Box 24

Waitangi

CHATHAM ISLANDS

Ph: (03) 3050-033

Fax: (03) 3050-044

Email:info@cic.govt.nz

2.1 Are any additional resource consents required in relation to this proposal?

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2.2 A description of the activity to which this application relates is:

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2.3 The alternatives considered and the reasons for choosing this site are:

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2.4 Name and address of persons affected by this application:

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3.1 Provide an assessment of any effects that the proposed activity may have on the

environment, in particular:

(a) Any effect on those in the neighbourhood and, where relevant, the wider community

including any socio-economic and cultural effects:

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(b) Any physical effect on the locality, including any landscape and visual effects:

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(c) Any effects on ecosystems, including effects on plants or animals and physical

disturbance of habitats in the vicinity:

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(d) Any effect on natural and physical resources having aesthetic, recreational, scientific,

historical, spiritual, or cultural, or other special value for present or future

generations:

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(e) Any discharge of contaminates into the environment, including any unreasonable

emission of noise and options for the treatment and disposal of contaminates:

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(f) Any risk to the neighbourhood, the wider community, or the environment through

natural hazards or the use of hazardous substances or hazardous installations:

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3.2 Outline any other relevant information:

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4.1 Where the application is for a subdivision consent, the following additional information is

required:

(a) the position of all new boundaries;

(b) the areas of all new allotments;

(c) the location and areas of new reserves to be created including any esplanade reserves

to be set aside on a survey plan under Section 189;

(d) the location and areas of land below mean high water springs of the sea or of any

point of the bed of a river or lake which is to be vested in the Crown under Section

191 of the Act;

(e) the location and areas of land to be set aside as new road;

(f) the provisions of access and all easements. The latter shall be clearly designed and

accompanied by a schedule stating the allotments subject and appurtenant to the

easements shown on the plan;

(g) physical features, including buildings on any proposed new allotment as well as

buildings on the balance of the land being subdivided;

(h) contours and spot heights in sufficient detail to determine the approximate grades of

roads, the general siting of the buildings and the general level of the land being

subdivided; and

(i) on each lot a site suitable for building and disposal of effluent must be determined

and located on the plan. Where necessary provide information relating to the bearing

capacity of proposed building site.

4.2 Generally, the information to accompany this application shall include:

(a) Site Plan showing (as appropriate):

i. Location to all existing and proposed buildings and distances to

boundaries (indicate those to which this application relates);

ii. Elected ground heights and/or land contours;

iii. Location of trees, streams, drains, and other topographical features;

iv. Existing and proposed access points and internal roading;

v. Existing and proposed car-parking areas;

vi. Location of archaeological sites on the property;

vii. Location of existing septic tanks and effluent drainage lines, or a proposed

water and sewerage connection and stormwater disposal;

viii. Details of proposed landscaping;

ix. Location of existing and proposed signs;

x. Areas and dimensions of property;

xi. Roads on to which the property has frontage;

xii. Present use of adjoining properties.

(b) Floor plan of all buildings relating to the application.

(c) Elevations of all new buildings to show external appearance.

(d) Size and design of advertising signs.

Note: All plans are to be to scale.

20day ofthisDated at……………………………………. …………… …………………….. …….

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Signature of applicant or person

authorised to sign on behalf of applicant.

Address for Service of Applicant

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Phone No…………………………………………………

Application for Resource Consent

Section 88, Resource Management Act 1991

To (name of local authority or regional council in the case of a coastal permit).

I, (full name), apply for the following type(s) of resource consent:

(For any activity in the coastal marine area, state coastal permit. Otherwise state 1 or more

of the following: land use consent, subdivision consent, water permit, or discharge permit.

Describe the activity to which the application relates.)

*The names and addresses of the owner and occupier (other than the applicant) of land to

which the application relates are as follows:

(Give names and addresses)

*Delete if not applicable

The location of the proposed activity is as follows:

(Describe the location as it is commonly known and in a way that will enable it to be easily

identified e.g. the street address, the legal description, the name of any relevant stream,

river, or other water body to which the application relates, proximity to any well-known

landmark, the grid reference if known).

No additional resource consents are needed for the proposed activity (or the following

additional resource consents are needed for the proposed activity and have (or have not)

been applied for: (Give details).

I attach, in accordance with the Fourth Schedule of the Resource Management Act 1991,

an assessment of environmental effects in the detail that corresponds with the scale and

significance of the effects that the proposed activity may have on the environment.

I attach any information required to be included in this application by the District Plan,

the Regional Plan, the Resource Management Act 1991, or any regulations made under

that Act.

(List all documents that you are attaching).

*As this is an application for a subdivision consent, I attach information that is sufficient

to adequately define:-

(a) the position of all new boundaries; and

(b)** the areas of all new allotments; and

(c) the locations and areas of new reserves to be created, including any esplanade

reserves and esplanade strips; and

(d) the locations and areas of any esplanade reserves, esplanade strips and access

strips; and

(e) the locations and areas of land below mean high water springs of the sea, or of

any part of the bed of a river or lake, to be vested in the Crown or local authority

under Section 237a of the Resource Management Act 1991; and

(f) the locations and areas of land to be set aside as new roads.

*(Delete if this is not an application for a subdivision consent).

** (Delete if the subdivision involves a cross-lease, company lease, or unit plan).

*As this is an application for a resource consent for reclamation, I attach

information to show the area proposed to be reclaimed, including its location, the

position of all new boundaries, and the portion of that area (if any) to be set apart

as an esplanade reserve or esplanade strip.

*Delete if this is not an application for a resource consent for reclamation

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Signature of applicant (or person authorised to sign on behalf of applicant)

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Date

Address for service of applicant:

Telephone:

Fax/Email:

Contact person: (name and designation, if applicable)

Note to applicant

You may apply for 2 or more resource consents that are needed for the same

activity on the same form.

You must pay the charge payable to the consent authority for the resource consent

application under the Resource Management Act 1991 (if any). If the application is

for a coastal permit for a restricted coastal activity, you must also pay the

application fee stated in Schedule 2 of the Resource Management (Forms, Fees,

and Procedure) Regulations 2003.

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