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 Planning and Land 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/s	
	Section 		Suburb		Unit No.		
		
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 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 please ensure your email address is provided. 

Rule Departure/s – Residential Land ONLY
NOTE: An application for a departure from the requirements of a mandatory rule will not be approved
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 

Is the work detailed in this application currently under construction?	•	YES	•	NO	
Is this application for an existing structure?	•	YES	•	NO	
Is the application being considered subject to a current Building Approval?
If YES – provide building approval project number BA ______________________	•	YES	•	NO	
			
Is the application subject to a completed Building Approval?	•	YES	•	NO	
Is this application currently subject to compliance action?	•	YES	•	NO	

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

Applicant Declaration If there are more than two lessees please ensure that the details and authorisation are attached to the application.

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	
	Date		
				
Lessee 2 Signature	
	Date		

Privacy Notice
The personal information on this form is provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Planning and Development Act 2007.  If all or some of the personal information is not collected EPD cannot process your application. 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. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the development assessment process.  The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably believes that the use or disclosure of the information is reasonably necessary for enforcement-related activities conducted by, or on behalf of, an enforcement body. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.environment@act.gov.au 

Contact Details:
Environment and Planning Directorate
Customer Service Centres
GPO Box 158, Canberra City 2601
8 Darling Street Mitchell, ACT 2911
16 Challis Street Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923	TTY: (02) 6207 2622
Email: epdcustomerservices@act.gov.au	Website: www.environment@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 
Planning and Land Authority
	
Date:……./……./ 20……