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Householder Application for Planning Permission for works or
extension to a dwelling and conservation area consent.
Town and Country Planning Act 1990
Planning (Listed Buildings and Conservation Areas Act) 1990
You can complete and submit this form electronically via the Planning Portal by visiting www.planningportal.gov.uk/apply
Publication of applications on planning authority websites
Please note that the information provided on this application form and in supporting documents may be published on the
Authority’s website. If you require any further clarification, please contact the Authority’s planning department.
Please complete using block capitals and black ink.
It is important that you read the accompanying guidance notes as incorrect completion will delay the processing of your application.
1. Applicant Name and Address
Title: First name:
Last name:
Address 1:
Address 2:
Town:
Address 3:
County:
Country:
Postcode:
Company
(optional):
House
number:
House
name:
House
suffix:
Unit:
2. Agent Name and Address
Title:
House
name:
House
suffix:
House
number:
Unit:
Company
(optional):
First name:
Last name:
Address 1:
Address 2:
Town:
Address 3:
County:
Country:
Postcode:
3. Description of Proposed Works
Please describe the proposed works:
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4. Site Address Details
Please provide the full postal address of the application site.
House
name:
House
suffix:
House
number:
Unit:
Address 1:
Address 2:
Town:
Address 3:
County:
Postcode
(optional):
Easting: Northing:
Description of location or a grid reference.
(must be completed if postcode is not known):
Description:
Is a new or altered vehicle access
proposed to or from the public highway?
Yes
No
Is a new or altered pedestrian access
proposed to or from the public highway?
Yes
No
Do the proposals require any diversions,
extinguishments and/or creation of public
rights of way?
Yes No
If Yes to any questions, please show details on your plans or
drawings and state the reference number(s) of the plan(s)/
drawing(s)
5. Pre-application Advice
Has assistance or prior advice been sought from the local
authority about this application?
NoYes
If Yes, please complete the following information about the advice
you were given. (This will help the authority to deal with this
application more efficiently).
Please tick if the full contact details are not
known, and then complete as much as possible:
Officer name:
Reference:
Date (DD/MM/YYYY):
(must be pre-application submission)
Details of the pre-application advice received:
Has the work already started?
NoYes
If Yes, please state when the work was started (DD/MM/YYYY):
(date must be pre-application submission)
Has the work been completed?
NoYes
If Yes, please state when the work was completed (DD/MM/YYYY):
(date must be pre-application submission)
3. Description of Proposed Works (continued)
7. Trees and Hedges
Are there any trees or hedges on your own
property or on adjoining properties which
are within falling distance of your boundary?
Yes No
If Yes, please mark their position on a scaled
plan and state the reference number of any plan(s)/drawing(s):
Will any trees or hedges need to be removed
or pruned in order to carry out your proposal?
No
Yes
If Yes, please show on your plans which trees by giving them
numbers e.g. T1, T2 etc, state the reference number of the plan(s)/
drawing(s) and indicate the scale.
6. Pedestrian and Vehicle Access, Roads and Rights of Way
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8. Parking
Will the proposed works affect
existing car parking arrangements?
Yes
No
If Yes, please describe:
11. Explanation For Proposed Demolition Work
Why is it necessary to demolish all or part of the building(s) and or structure(s)?
10. Materials
If applicable, please state what materials are to be used externally. Include type, colour and name for each material:
Existing
(where applicable)
Proposed
Not
applicable
Don't
Know
Walls
Roof
Windows
Doors
Boundary treatments
(e.g. fences, walls)
Vehicle access and
hard-standing
Lighting
Others
(please specify)
Are you supplying additional information on submitted plan(s)/drawing(s)/design and access statement?
Yes
No
If Yes, please state references for the plan(s)/drawing(s)/design and access statement:
9. Authority Employee / Member
With respect to the Authority, I am:
a) a member of staff
b) an elected member
c) related to a member of staff
d) related to an elected member
Yes No
If Yes, please provide details of the name, relationship and role
Do any of these
statements apply to you?
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12. Ownership Certificates
One certificate A, B, C, or D must be completed, together with the Agricultural Holdings Certificate with this application form
CERTIFICATE OF OWNERSHIP - CERTIFICATE A
Certificate under Article 7 of the Town and Country Planning (General Development Procedure) Order 1995 &
Regulation 6 of the Planning (Listed Buildings and Conservation Areas) Regulations 1990
I certify/The applicant certifies that on the day 21 days before the date of this application nobody except myself/ the applicant was the
owner (owner is a person with a freehold interest or leasehold interest with at least 7 years left to run) of any part of the land or building to
which the application relates.
Date (DD/MM/YYYY):
Or signed - Agent:Signed - Applicant:
CERTIFICATE OF OWNERSHIP - CERTIFICATE B
Certificate under Article 7 of the Town and Country Planning (General Development Procedure) Order 1995 &
Regulation 6 of the Planning (Listed Buildings and Conservation Areas) Regulations 1990
I certify/ The applicant certifies that I have/the applicant has given the requisite notice to everyone else (as listed below) who, on the day
21 days before the date of this application, was the owner (owner is a person with a freehold interest or leasehold interest with at least 7 years
left to run) of any part of the land or building to which this application relates.
Name of Owner
Address
Date Notice Served
Date (DD/MM/YYYY):Or signed - Agent:Signed - Applicant:
CERTIFICATE OF OWNERSHIP - CERTIFICATE C
Certificate under Article 7 of the Town and Country Planning (General Development Procedure) Order 1995 &
Regulation 6 of the Planning (Listed Buildings and Conservation Areas) Regulations 1990
I certify/ The applicant certifies that:
Neither Certificate A or B can be issued for this application
All reasonable steps have been taken to find out the names and addresses of the other owners (owner is a person with a freehold
interest or leasehold interest with at least 7 years left to run) of the land or building, or of a part of it , but I have/ the applicant has
been unable to do so.
The steps taken were:
Name of Owner
Address
Date Notice Served
Notice of the application has been published in the following newspaper
(circulating in the area where the land is situated):
On the following date (which must not be earlier
than 21 days before the date of the application):
Signed - Applicant: Or signed - Agent: Date (DD/MM/YYYY):
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12. Ownership Certificates (continued)
CERTIFICATE OF OWNERSHIP - CERTIFICATE D
Certificate under Article 7 of the Town and Country Planning (General Development Procedure) Order 1995 &
Regulation 6 of the Planning (Listed Buildings and Conservation Areas) Regulations 1990
I certify/ The applicant certifies that:
Certificate A cannot be issued for this application
All reasonable steps have been taken to find out the names and addresses of everyone else who, on the day 21 days before the
date of this application, was the owner (owner is a person with a freehold interest or leasehold interest with at least 7 years left to run)
of any part of the land to which this application relates, but I have/ the applicant has been unable to do so.
Notice of the application has been published in the following newspaper
(circulating in the area where the land is situated):
The steps taken were:
On the following date (which must not be earlier
than 21 days before the date of the application):
Date (DD/MM/YYYY):
Or signed - Agent:
Signed - Applicant:
14. Planning Application Requirements - Checklist
Please read the following checklist to make sure you have sent all the information in support of your proposal. Failure to submit all
information required will result in your application being deemed invalid. It will not be considered valid until all information required by
the Local Planning Authority has been submitted.
The original and 3 copies of other plans
and drawings or information necessary to
describe the subject of the application:
The original and 3 copies of a
design and access statement where
proposed works fall within one of
the following designated areas:
National Park
Site of special scientific interest
Conservation area
Area of outstanding natural beauty
World Heritage Site
The correct fee:
The original and 3 copies of the
completed, dated Ownership Certificate
(A, B, C or D - as applicable):
The original and 3 copies of the
completed, dated Article 7 Certificate
(Agricultural Holdings):
The original and 3 copies of a
completed and dated application form:
The original and 3 copies of a plan which
identifies the land to which the application
relates drawn to an identified scale
and showing the direction of North:
AGRICULTURAL HOLDINGS CERTIFICATE
Town and Country Planning (General Development Procedure)Order 1995 Certificate under Article 7
Agricultural Land Declaration - You Must Complete Either A or B
(A) None of the land to which the application relates is, or is part of, an agricultural holding.
Name of Tenant
Address
Date Notice Served
Date (DD/MM/YYYY):Or signed - Agent:
Signed - Applicant:
Signed - Applicant: Or signed - Agent:
Date (DD/MM/YYYY):
(B) I have/ The applicant has given the requisite notice to every person other than myself/ the applicant who, on the day 21 days
before the date of this application, was a tenant of an agricultural holding on all or part of the land to which this application relates,
as listed below:
13. Agricultural Holdings
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16. Applicant Contact Details
Telephone numbers
Country code:
National number:
Extension
number:
Country code:
Mobile number (optional):
Country code:
Fax number (optional):
Email address (optional):
17. Agent Contact Details
Telephone numbers
Country code:
National number:
Extension
number:
Country code:
Mobile number (optional):
Country code:
Fax number (optional):
Email address (optional):
18. Site Visit
Can the site be seen from a public road, public footpath, bridleway or other public land?
No
Yes
If the planning authority needs to make an appointment to carry
out a site visit, whom should they contact? (Please select only one)
Other (if different from the
agent/applicant's details)
ApplicantAgent
If Other has been selected, please provide:
Contact name: Telephone number:
Email address:
15. Declaration
I/we hereby apply for planning permission/consent as described in this form and the accompanying plans/drawings and additional
information.
Or signed - Agent:Signed - Applicant: Date (DD/MM/YYYY):
(date cannot be
pre-application)
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