Departures from the numerical controls in the Rules of the Single Residential Housing Development Code will only be considered in relation to building envelope controls, the minimum dimension for private open space and setbacks for proposed development on residential land.  The Authority may only approve a minor departure/s where no-one other than the applicant will be adversely affected by the departure and the environmental impact caused by the approval of the departure will do no more than minimally increase the environmental impact of the development.

Lease/Site Details Please Print

If more than one lease/site, attach the following details for each lease/site

Block	

Section	
	Unit (if applicable)		
		
Suburb	

District	

Street Number	

Street Name	

Postcode	

Applicant/Certifier Details Please Print

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Lessee (Property Owners) Details Please Print

1st Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

2nd Lessee’s Details 

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the lodgement of this development application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Decision and Plans

Unless otherwise specified your decision and plans will be returned via email

•	EMAIL		•	POST TO ME		•	HOLD FOR COLLECTION	

Rule Departure/s – Residential Land ONLY

This application seeks approval for the following minor departure/s from the Single Residential Housing Development Code  

Rule Number	Description of Departure	

	

	

	

*Relevant plans and supporting documentation that clearly identify the rule departure/s must be provided at the time of lodgement 

Applicant Declaration

I/we declare that this application is accompanied by all of the required information or documents 

I/we declare that all the information given on this form and its attachments is true and complete.

Applicant Signature (s)	
	Date		
				
Lessee 1 Signature (s)	
	Date		
				
Lessee 2 Signature (s)	
	Date		
	
If there are more than two lessees please ensure that the details and authorisation are attached to the application.
	
Privacy Notice
The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ACTEWAGL, ACTEW Corporation and other commercial organisations interested in development and building information. The Planning and Development Act 2007 requires the details of applications, decisions and orders to be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made available via the Internet.

Contact Details:
ACT Planning and Land Authority
Customer Service Centre
GPO Box 1908, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923		Fax: (02) 6207 1925		TTY: (02) 6207 2622
Email: actpla.customer.services@act.gov.au	Website: www.actpla.act.gov.au

OFFICE USE ONLY

            ASSESSMENT OF PROPOSAL
             DETERMINATION UNDER SECTION 1.100A OF THE 
              PLANNING AND DEVELOPMENT REGULATION 2008

Description of Extended Distance:

____________________________________________

Assessment:

	PASS	FAIL	
			
Is the non-compliance minor?	•	YES	•	NO	
			
Will building the dwelling other than in accordance with the relevant rules:
	
•	adversely affect someone other than the applicant?	•	NO	•	YES	
			
•	increase the environmental impact of the dwelling more than minimally?	•	NO	•	YES	
			
Plans provided adequately identify departures	•	YES	•	NO	

Comments:

____________________________________________

Approved  /  Refused			

Plans Stamped					…………………………………
Delegate of the 
ACT Planning and Land Authority
	
Date:……./……./ 20……