Form 10 Application for Change or Cancellation of Resource Consent
Condition
(Section 127, Resource Management Act 1991)
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To:
Planning Department
Horowhenua District Council
126 Oxford Street
Private Bag 4002
LEVIN 5540
Please Note
The initial fee payment is a deposit only. There will be additional charges for actual staff time spent processing
your application, which will be invoiced at the completion of the application. This is based on an hourly rate set in the
schedule of Planning Fees and Charges.
Completing this form
This form provides us with your contact details, and details about what you propose and its actual and potential
effects on the environment. Note that all the information provided in your application is available to the public.
We recommend that you talk your proposal through with Council staff before you fill in this form and when you lodge
your application. You should also contact us if you are unsure which forms you should be using, or if you need help
with filling in any of the forms.
1. APPLICANT DETAILS
I/We (Full name/s of Applicant(s)):
apply for a
Change of condition
Cancellation of a condition
of a Resource Consent
2. RESOURCE CONSENT DETAILS
My application relates to the following resource consent:
Land Use Consent Subdivision Consent
Council Resource Consent No:
Briefly describe the type of resource consent below eg. subdivision to create an additional residential Lot or land
use consent to relocate a building:
3. LOCATION DETAILS (location of the consented activity)
Street/Road Address:
Legal
Description:
Lot: DP CT
Area (hectares/square
metres)
Valuation Reference No.
Please describe the location as it is commonly known and in a way that will enable it to be easily identified (e.g.
the name of any relevant stream, river or other water body to which the application relates, proximity to any well
known landmark:
4. AFFECTED RESOURCE CONSENT CONDITION DETAILS
My application relates to the following specific condition of the resource consent: (please identify the number/s
of the condition/s and quote the entire condition/s of the resource consent).
5. PROPOSAL DETAILS
The Proposed Change is as follows (give details):
Or
It is proposed to cancel condition:
detailed above(give details)
6. ASSESSMENT OF ENVIRONMENTAL EFFECTS (See NOTE below)
I attach, in accordance with Schedule 4 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
change to, or cancellation of, the activity may have on the environment. Generally the larger or more
complex the proposal and effects, the more detailed this assessment should be; for minor proposals,
use the space below.
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.
Attached: Yes No
NOTE:
Assessment of Environmental Effects (AEE)
An AEE is an essential part of the application. If an AEE is not provided the application will be considered
incomplete and will not be accepted for processing. The AEE should discuss all the actual and potential effects on
the environment arising from the proposal. The amount of detail provided must reflect the nature and scale of the
effects. For example, if there are major effects arising from the proposal, a detailed analysis and discussion of these
effects should be included in the AEE. It may require the provision of information from specific experts such as an
acoustic consultant or traffic engineer. If the effects of the proposal are very minor then a less detailed AEE can be
submitted.
For more information see the Fourth Schedule of the Resource Management Act 1991 which lists the matters to be
covered in an AEE.
Please refer to the assessment criteria contained within the Horowhenua District Plan that are specific to the type of
application you applying for. These will help focus you on the types of effects that need to be addressed in your
assessment. These criteria are identified in Section 25 of the Plan and are specific to both subdivision and land use
applications.
Key questions that should be addressed in an AEE
Is this proposal likely to have any negative effects beyond the boundary of the site (for example, shading from a
building that can’t comply with height requirements)?
Can such a negative effect be avoided, remedied or mitigated (for example, significant trees growing on the
boundary of the potentially shaded property which will more than eclipse potential shading from the proposed
building)?
Is the proposal likely to have any positive effects (for example, a potentially dangerous vehicle crossing will be
closed and moved to a safer location)?
If you have trouble compiling the information, or need some advice on aspects of your application, please consult
Council’s Duty Planner - a planner is always available to assist with planning enquiries to provide assistance.
Further information relative to an AEE for both subdivision and land use applications is contained in Section 28 of
the District Plan and Council's "Subdivision and Development Principles and Requirements 2012".
7. SIGNED WRITTEN APPROVAL FORMS
I/We have consulted and obtained the written approval of the following persons adversely affected by the
proposal:
Number of forms attached:
8. APPLICANT/CONSULTANT DETAILS
APPLICANT'S DETAILS APPLICANT'S CONSULTANT'S DETAILS
(if applicable)
Applicant's Address: Consultant's Address:
Applicant's Phone: Applicant's Mobile: Consultant's Phone: Consultant's Mobile
Applicant's Email: Consultant's Email
Address for Service (if different from above). Name and Address Application will be invoiced to:
9. PAYMENT DETAILS
You must pay the fee (fixed charge) payable to the consent authority for the application to change or cancel a
condition of a resource consent under the Resource Management Act 1991.
The costs associated with this application can be found on Council's Fees and Charges
page.
Payment can be made by cheque, EFTPOS or cash.
It is recommended that payment is made electronically using internet banking. Council’s Bank details are:
Name:
Horowhenua District Council
Bank:
BNZ
Branch:
Levin
Account Number:
02-0668-0070607-02
Ensure you include your name (e.g. AB SMITH), Consent Number (2014.3450) and the reason for payment (e.g.
RES CONS) in the Particulars and Reference sections when making payment. No action will be taken on your
application until payment has been receipted by Council and matched to your application. To speed things up send
evidence of your payment with your application email.
Please note: On receipt of an application, Council will determine whether the application needs to be notified
and will then advise you of the required notification fee. No application will be processed until Council is satisfied
that all information needed to assess the application is received, together with the necessary fee.
Should it be necessary for Council to refund part or all of the fee paid, please provide below the details of the bank
account you wish this to be paid to.
Account Name Bank Account Number
10. DECLARATION
The information provided in this form is true and correct:
By typing your name in the space provided below, you are 'electronically signing' this form
Name: Date:
HDC is committed to being environmentally sustainable, therefore please submit your application
electronically to:
recordsprocessing@horowhenua.govt.nz
If you require further information please contact a member of our Customer Experience team on:
06 366 0999
OFFICE USE ONLY
Council Officer Date:
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