CONSENT HOLDER // Must be a person or legal entity (limited liability company or trust). Full names of all trustees required.
DETAILS OF SITE // LOCATION
BILL PAYER //
The invoices will be sent to this postal address or email.
APPLICANTS REPRESENTATIVE // Agent / Individual submitting application and receive all correspondence throughout process
Applicant’s full name:
Company / Trust:
Contact Person / All trustee names:
Address / Location to which this application relates:
Legal Description:
Can be found on the Computer Freehold Register or Rates Notice – e.g Lot x DPxxx (or valuation number)
Owners / Occupiers of the Site: If dierent from applicant above
OR:
Phone Numbers: Day Mobile:
Email Address:
Postal Address: Post code:
Name & Company:
Phone Numbers: Day Mobile:
Email Address:
Our preferred methods of corresponding with you are by email and phone.
Please provide an email AND full address.
Page 1/4 // June 2017
S223 & S224
APPLICATION FORM
SUBDIVISION DETAILS
Date applied for:
New Deposited Plan Number:
Stage:
No. of Lots
(excl roads/reserves)
CONSENT NUMBERS  Including all Variations
CONSENT DESCRIPTION
DATE CONSENT ISSUED
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E:
subdivision@qldc.govt.nz
www.qldc.govt.nz
Page 2/4 // June 2017
CERTIFICATES TO BE SIGNED
Cert
223
224f
32(2)(a)
243
224c
239
226
and/or
241(4)
To be signed
with:
Easements
Amalgamation
Unit Measurability
Easement
Cancellation
Consent Notice
(221)
Registered Bond
Reserve interests
to remain
Part cancellation
of existing
amalgamations
Developer Comments QLDC Comments
APPROVALS TO BE SUBMITTED WITH APPLICATION
Approval From:
Engineering approv-
al(s) obtained and all
conditions of engineering
approval satised
(or USC if appropriate)
Landscape Architect
(required if any private
landscaping consented)
Parks and Reserves
(required if reserves are
vesting, or if PED rows/
cycleways are vesting as
easements in gross and
if any trees are planted in
road reserves)
Road Names
Interests to remain on
Council Reserves
Developer Comments QLDC Comments
List relevant BCs
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: subdivision@qldc.govt.nz
www
.qldc.govt.nz
Page 3/4 // June 2017
APPLICATION & DECLARATION
The Council relies on the information contained in this application being complete and accurate. The Applicant must take all reasonable
steps to ensure that it is complete and accurate and accepts responsibility for information in this application being so.
If lodging this application as the Applicant:
I/we hereby represent and warrant that I am/we are aware of all of my/our obligations arising under
this application including, in particular but without limitation, my/our obligation to pay all fees and
administrative charges (including debt recovery and legal expenses) payable under this application as
referred to the Fees Information section.
If lodging this application as agent of the Applicant:
I/we hereby represent and warrant that I am/we are authorised to act as agent of the Applicant in
respect of the completion and lodging of this application and that the Applicant is aware of all of his/
her/its obligations arising under this application including, in particular but without limitation, his/her/
its obligation to pay all fees and administrative charges (including debt recovery and legal expenses)
payable under this application as referred to the Fees Information section.
Signed (by or as authorised agent of the Applicant) **
Full name of person lodging this form
Firm/Company Dated
**If this form is being completed on-line you will not be able, or required, to sign this form and the on-line lodgement will be treated as
conrmation of your acknowledgement and acceptance of the above responsibilities and liabilities and that you have made the above
representations, warranties and certication.
OR:
PRIVACY INFORMATION
The information you have provided on this form is required so that your application can be processed under the Resource Manage-
ment Act 1991 and may also be used in statistics collected and provided to the Ministry for the Environment and Queenstown Lakes
District Council. The information will be stored on a public register and may be made available to the public on request or on the
company’s or the Council’s websites.
FEES INFORMATION
An initial fee for processing this application will be charged at the time of lodgement in accordance with QLDC’s fee schedule. This
initial fee must accompany your application for processing to commence. If the initial fee is insucient to cover the actual and
reasonable costs of work undertaken on the application you will be required to pay any additional amount and will be invoiced
monthly as work on the application continues. Please note that if the Applicant has outstanding fees owing to Council in respect of
other applications, Council may choose to apply the initial fee to any outstanding balances in which case the initial fee for processing
this application may be deemed not to have been paid.
Invoiced sums are payable by the 20th of the month after the work was undertaken. If unpaid, the processing of an
application, provision of a service, or performance of a function will be suspended until the sum is paid. You may also be
required to make an additional payment, or bring the account up to date, prior to milestones such as notication, setting a
hearing date or releasing the decision. In particular, all charges related to processing of an application are payable prior to
issuing of the approval. Payment is due on the 20th of the month or prior to the issue date – whichever is earlier.
LIABILITY FOR PAYMENT – Please note that by signing and lodging this application form you are acknowledging that the
Applicant is responsible for payment of invoices and in addition will be liable to pay all costs and expenses of debt recovery
and/or legal costs incurred by QLDC related to the enforcement of any debt.
INFORMATION TO BE SUBMIT TED // Attach with this form
L.T Plan
Completed Subdivision 224c Checklist
All correspondence documents in regards to the conditions
Please ensure documents are scanned at a minimum resolution of 300 dpi
Each document should be no greater than 10mb
Please upload via our Sharefile portal or send directly to subdivision@qldc.govt.nz
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: subdivision@qldc.govt.nz
www
.qldc.govt.nz
Page 4/4 // June 2017
click to sign
signature
click to edit
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