Type of Application
•	New Application		
(If you attended a pre-application meeting or received pre- application written advice- please provide the proposal number)	
Insert Proposal Number to which this application relates (if applicable):

20………………..
	
•	Additional Information as requested by 
ACT Planning and Land Authority	Insert Proposal Number to which this application relates (if applicable):

20………………..	
•	Request for Exemption to Provide Environmental Impact Statement
Section 211 Planning and Development Act 2007

Lease/Site Details Please Print

Provide the following details for each lease/site:

Site 1
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

Site 2
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

Site 3
Block:	
	Section:		Suburb:		
		
Street Address (if applicable)	

Land Use Zone/s applicable to this site	

If more than three sites please provide details on separate page

Applicant Details Please Print

Surname	
		First Name		
Name of Company/Department/ Government Agency 	

Position held in Company/Department/Government Agency		
		
Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Lessee (Property Owners) or Government Land Custodian Details Please Print

SITE 1

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

SITE 2

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

SITE 3

1st Lessee or Land Custodian Details
	               2nd Lessee or Land Custodian Details	
Full Name:
		Full Name:		
				
Company Name:
		Company Name:		
				
Position Held in Company:		Position Held In Company:		
				
ACN Number:
		ACN Number:		
				
Postal Address:

	Postal Address:		
				
Telephone BH:		Telephone BH:		
				
Mobile:
		Mobile:		
				
Email Address:
		Email Address:		

All lessees must sign authorising the lodgement of this 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.

If a lessee signature can not be obtained and either a land acquisition or lease withdrawal is underway to facilitate the project to which the EIS Scope relates then the applicant must submit documentary evidence that such land acquisition or lease withdrawal is occurring and that the lessee is aware of the project to which the EIS Scope relates.

EIS Requirements

Please identify why your proposal requires an Environmental Impact Statement and include applicable references to the Planning and Development Act 2007.

	

	

	

Your Proposal 

Please attach to this application form a document that provides sufficient detail to enable prescribed entities to obtain an understanding of the full extent of your proposal and any associated works, including; 

1.	a statement outlining the objective of the project and why it is needed;

2.	description of the nature/type of project proposed by providing;

a.	location map(s) of the project site(s);
b.	detailed concept and layout plan showing all proposed buildings, structures, plant and equipment and other facilitates (temporary and permanent);
c.	the nature, sources, location and quantities of all materials to be handled on site including the storage and stockpiling of raw materials;
d.	access, internal roads, car parking, equipment compounds and proposed infrastructure associated with the project;
e.	all activities, including chemical and mechanical to be conducted as part of the project;
f.	waste treatment process involved, including site drainage, and erosion control;
g.	life of the project and employment projections;
h.	volume and characteristics of liquid and solid wastes generated;
i.	construction methods;
j.	hours of work (construction and operational);
k.	existing infrastructure available on and adjacent to the project site(s);
l.	extent of any clearing of vegetation; and
m.	 land tenures affecting the project site(s).

Environment Protection and Biodiversity Conservation Act 1999

Does the Commonwealth Environment Protection and Biodiversity Conservation Act 1999 (EPBC) affect your proposal?
	•	NO
•	YES
	
If YES, attach copies of the DEWHA "Notification of Referral Decision" and "Decision on Assessment Approach" (Copies of the DEWHA "Notification of Referral Decision" and the "Decision on Assessment Approach" must be attached to this application form before it can be accepted for processing by ACTPLA)
	
If NO - Have you had meetings/discussions with the Commonwealth Department of Environment, Water, Heritage and the Arts (DEWHA)?	•	NO
•	YES
	
If YES 
Please provide name & contact details of DEWHA officer	
Name:         ____________________________	
	
Contact No. ___________________________
	
EIS Not Required if Development Application Exempted – S.211 Planning & Development Act 2007

The Minister may exempt a development application for development approval for a development proposal from a requirement to include an EIS if satisfied that the expected environmental impact of the development proposal has already been sufficiently addressed by another study, whether or not the study relates to the particular development proposal.

Are you seeking consideration under s.211 ?	

•	NO
•	YES	

IF YES 
Please supply supporting documentation to justify s211 consideration and  a statement as to how the supporting documentation satisfies the requirement of s.211 

•	Documentation Attached

Prescribed Entities

Have you had any meetings/discussions with relevant prescribed entities?	
•	NO
•	YES	
IF YOU ANSWERED YES TO THE PREVIOUS QUESTION– please complete the following table:

ENTITY (please tick)	DATE/s OF MEETING/s	ENTITY CONTACT 	
•	ACTEW Corporation Ltd	
		
•	ACTEWAGL Distribution	
		
•	Conservator Flora & Fauna	
		
•	Emergency Services	
		
•	Environment Protection	
		
•	Heritage Council	
		
•	Health Policy	
		
•	Territories & Municipal Services	
		
•	Custodian of the Land	

•	Other   -------------------------------------			

Conflict of Interest Declaration

Does the applicant or lessee have any association with ACT Planning and Land Authority staff?	•	NO
•	YES	
If YES please provide details:	

NOTE: There are penalties for deliberately giving false and misleading information. The Planning and Land Authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Other Application Requirements

DOCUMENTATION AND PLANS
All required documentation must be provided in an electronic format on compact disc/DVD and meet the following requirements (Form can be submitted in hardcopy if lodged over the counter)

•	Each document must be saved as a PDF and named in accordance with the naming convention as detailed on the ACTPLA website. 
•	All plans must be to scale.
•	All plans must be rotated to the correct orientation i.e. they are the right way up when opened
•	All plans are to be clear and concise and generally consistent with Australian Standard 1100.301 - 1985 and Australian Standard 1100.301 supplementary - as updated from time to time.
•	The proposal number included in the naming convention is unique to the application and provided by the ACT Planning and Land Authority. If you have already had dealings with the Authority about your proposal through a pre-application meeting or have requested and received pre application advice, you would already have a proposal number allocated for your development application. If you have not been allocated a proposal number, leave this number out of the file name. 
•	The documentation provided on CD/DVD either over the counter or via an electronic lodgment process (email or internet) will be considered to be the relevant documentation associated with this application.

HARDCOPY DOCUMENTATION REQUIREMENTS

In addition to the documentation being provided on CD/DVD one bound and one unbound hard copy must also be provided. 

Applicant and Lessee Declaration

I/we the undersigned, herby apply for a Final Scoping Document;

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

I/we understand that the information submitted with this application form will undergo a documentation check.  I/we understand that this application will be considered lodged once the relevant application fees have been paid;

I/we understand that the documentation provided on CD/DVD will be considered to be the relevant documentation associated with this application;

I/we hereby authorise ACT government officers to access the subject property(s) for the purpose of evaluating the proposal;

I/we the undersigned (lessee) appoint the applicant whose name and signature appear below to act on my/our behalf in relation to this application.  This authorises the applicant to pay for all application fees, bonds, and securities, liaise with the ACT Planning and Land Authority when required, alter amend or provide further information as necessary and receive any communications relating to this application;

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

If signing on behalf of a company, organisation or Government agency: -
I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company, organisation or Government agency.

Applicant Signature (s)	
	Date		
SITE 1				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
Govt Land Custodian Signature 
(unleased land only)	
	Date		
				
Delegate of ACTPLA 
(unleased land only)	
	Date		
SITE 2				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
Govt Land Custodian Signature 
(unleased land only)	
	Date		
				
Delegate of ACTPLA 
(unleased land only)	

	Date		
SITE 3				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
Govt Land Custodian Signature 
(unleased land only)	

	Date		
				
Delegate of ACTPLA 
(unleased land only)	

	Date		

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 maybe 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.

Does the Commonwealth Environment Protection and Biodiversity Conservation Act 1999 (EPBC) affect your proposal?
The EPBC came into operation on 16 July 2000. It establishes an environmental assessment and approval system that is separate and distinct from the ACT system. It does not affect the validity of ACT development assessment and approval processes, but may affect the assessment track. The ACT cannot provide preliminary advice on whether a proposal falls within the definition of a controlled action, or requires referral to the Commonwealth. You should consult with the Commonwealth to determine if your proposal is a controlled action before seeking any approvals under the Planning and Development Act 2007. For information about the EPBC, including the referral process and when a referral should be made, contact the Department of the Environment, Water, Heritage and the Arts, GPO Box 787, CANBERRA ACT 2601 Telephone: 62741111.

ACT Planning and Land Authority
Customer Service Centre, 16 Challis Street, Dickson ACT 2602
GPO Box 1908, Canberra City 2601
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