Date:
Name of Monumental Mason:
Name of Plot Owner or Next of Kin:
On approval of application for monument work an Approval Fax or email will be forwarded and must be carried at all
times while working in the Cemetery.
I hereby declare that all monumental masonry work carried out by the undersigned is done in accordance with
NZS 4242:1995 (Headstone and Cemetery Monuments), and also in accordance with Queenstown Lakes District
Council’s Cemetery Bylaw 2010. I further understand that failure to comply with the above standards will result in a
ne of up to $500.00.
I hereby give my permission for the erection of the work mentioned above, and in consideration of Council permitting the
execution of such work on the above plot, I the undersigned DO HEREBY INDEMNIFY and hold safe and harmless the
Council against all actions, proceedings, claims, demands, damages, costs, losses and expenses whatsoever which may be
made on or instituted against or suffered by the Council in any manner whatsoever by reason of the Council having consented
to the execution of such work.
Plot Number:
Fax:
Name of Legal Representative:
Block Number:
Signature of Monumental Mason:
Signature:
Application is hereby made for permission to carry out monumental work in the:
Address:
Address:
Address:
IN ACCORDANCE WITH NEW ZEALAND STANDARD HEADSTONE AND CEMETERY MONUMENTS: NZS 4242: 1995
[Cemetery]
AUTHORITY TO BE SIGNED BY OWNER OF PLOT(S)
Queenstown Lakes District Council will use personal information for the purposes for which it was collected, or as otherwise authorised
by the Privacy Act 1993 or any other legislation. The Council will share personal information with the Council’s contractors and agents for
the purposes of complying with the Council’s obligations, and carrying out its functions under the Burial and Cremation Act 1964. In all
other cases the Council will not share personal information with any third parties unless written permission is given by next of kin, or unless
authorised by the Privacy Act 1993 or any other legislation.
PRIVACY STATEMENT:
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MONUMENT PERMIT
APPLICATION FORM
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