Fillable S243E CERTIFICATE THIS FORM IS NOT REQUIRED IF (Queenstown Lakes District Council New Zealand)

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S243E CERTIFICATE THIS FORM IS NOT REQUIRED IF (Queenstown Lakes District Council New Zealand)

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APPLICANT //
CORRESPONDENCE DETAILS //
If you are acting on behalf of the applicant e.g. agent, consultant or architect
please ll in your details in this section.
Name & Company:
Phone Numbers: Day Mobile:
Email Address:
Our preferred methods of corresponding with you are by email and phone.
The decision will be sent to the Correspondence Details by email unless requested otherwise.
*Attention:
*Postal Address: *Post code:
*Email:
Applicant: Agent: Other, please specify:
Email: Post:
Please provide an email AND full postal address.
• Must be a person or legal entity (limited liability company or trust).
• Full names of all trustees required.
• The applicant name(s) will be the consent holder(s) responsible for the consent and any associated costs
.
*Applicant’s Full Name / Company / Trust:
(Name Decision is to be issued in)
All trustee names (if applicable):
Contact Name if company or trust:
*Postal Address: *Post code:
*Contact details supplied must be for the applicant and not for the agent acting on their behalf and must include a valid postal address
*Email Address:
*Phone Numbers: Day Mobile:
INVOICING DETAILS //
Invoices will be made out to the applicant but can be sent to another party if paying on the applicant’s behalf.
For more information regarding payment please refer to the Fees Information section of this form.
Please select a preference for who should receive any invoices and how they would like to receive them.
THIS FORM IS NOT REQUIRED IF THE EASEMENT CANCELALATION IS BEING
PROCESSED AS PART OF A S223 OR S224C APPLICATION
Page 1/3 // February 2019
Resource Management Act 1991
PLEASE COMPLETE ALL MANDATORY FIELDS* OF THIS FORM.
This form provides contact information and details of your application. If your form does not provide the required information it will be returned
to you to complete. Until we receive a completed form and payment of the initial fee, your application may not be accepted for processing.
APPLICATION FOR AN
EASEMENT CANCELLATION
S243E CERTIFICATE
ADDITIONAL INFORMATION //
Please provide below any additional information that is required under the
relevant provisions of the District Plan, Local Government Act 1974, Resource
Management Act 1991 or any regulation.
The initial deposit fee (refer to ‘Resource Consent and Engineering Fees and Other Charges’ for Signing and Sealing
Certications below (relevant category is: Signing and Sealing other plan or certicate)
Attachments: I attach (tick as appropriate)
Please remember to sign the certication if applicable and have the payment section signed by the party
responsible for payment.
Please note your application will not be accepted until all of the required information has been supplied to
Queenstown Lakes District Council.
Reasons for the cancellation - see website for more details: https://www.qldc.govt.nz/planning/resource-consents/
land-developments-and-subdivisions/
Copies of the Easement Instruments and Title Plans that created the original easements
Description of the easements being cancelled in respect of the benetted and burdened lots
A draft s243e certicate for checking (template available on website)
Other (please specify)
PRIVACY INFORMATION
FEES INFORMATION
The information you have provided on this form is required so that your application can be processed under the Local
Government Act 1974 and may also be used in statistics collected by QLDC and provided to the Ministry for the
Environment. 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.
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.
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 a resource consent application
are payable prior to issuing of the decision. 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.
We prefer to receive applications electronically
Please ensure documents are scanned at a minimum resolution of 300 dpi
Each document should be no greater than 10mb
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 1/3 // February 2019
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 complete and accurate.
If signing 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 signing as agent of the Applicant:
If signing 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.
I hereby apply for the resource consent(s) for the Proposal described above and I certify that, to the best of
my knowledge and belief, the information given in this application is complete and accurate.
Signed (by or as authorised agent of the Applicant) **
Name (of person signing)
PLEASE PRINT
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:
PLEASE TICK
PAYMENT // An initial fee must be paid prior to or at the time of the application and proof of payment submitted.
Please note processing will not begin until payment is received (or identied if incorrectly referenced).
I conrm payment by:
Bank transfer to account 02 0948 0002000 000
(If paying from overseas swiftcode is – BKNZNZ22)
Cheque payable to Queenstown Lakes District Council attached
Manual Payment at reception (can only be accepted once application has been lodged and
acknowledgement email received with your unique RM reference number)
*Reference
*Amount Paid
(For required initial fees refer to website for Resource Consent Charges or speak to the Duty Planner by phoning 03 441 0499)
*Date of Payment
Please reference your payments as follows:
Applications yet to be submitted: RM followed by rst 5 letters of applicant name e.g RMJONES
Applications already submitted: Please use the RM# reference that has been assigned to your application, this will have been
emailed to yourself or your agent.
Queenstown Lakes District Council
Private Bag 50072, Queenstown 9348
Gorge Road, Queenstown 9300
P: 03 441 0499
E: resourceconsent@qldc.govt.nz
www.qldc.govt.nz
Page 1/3 // February 2019
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S243E CERTIFICATE THIS FORM IS NOT REQUIRED IF (Queenstown Lakes District Council New Zealand)

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Completed 10 November 2020

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