Swimming Pool Certificate of Compliance Application Form (PDF ...

COMPLIANCE SERVICESCnr Queen Street and Broughton Street(PO Box 57) Campbelltown 2560Phone (02) 4645 4604 – Fax (02) 4645 4111 DX5114Certificate of Compliance Application - Swimming PoolsSection 24 Swimming Pools Act 1992Privacy StatementThe information requested by Council on this form may constitute personal information under the Privacy and Personal Information ProtectionAct 1998. Council is allowed to collect the information from you to consider this matter. Supplying this information is voluntary. However if youcannot or do not wish to provide the information, we may not be able to consider the matter. If you need further details, please contact thePrivacy Officer, Campbelltown City Council, cnr Queen and Broughton Streets, Campbelltown.PC……………./……………..Part 1Applicants name, address(We will post our reply to thisaddress)Note: The applicant must bean owner of the propertyApplicants DetailsMr Mrs Miss Ms OtherFamily Name (or Company Name)Given Names (or ACN)Postal Address / DXPhoneFaxPostcodeAlternative phoneEmailPart 2Location and titledescription of the propertyWe need this to correctlyidentify the landSite DetailsUnit, shop or suite Street No StreetSuburbSide of Street (north, south, etc)Nearest Cross StreetLot(s) Portion SectionDeposited Plan(s)Strata PlanBuilding name (if applicable)These details are available from rate notices, property deeds, or from councilproperty maps. If unsure ask for assistance.For access to the propertywe will need a contactpersonNameAddressPhone NoEmailPlease draw on the diagram where the swimming pool, fence & gate are situatedKeyInspection Diagram= pool= fence= gateVerge/nature stripHouseCompliance ServicesDW: 1497733DATA AND DOCUMENT CONTROLRevised Date: 17/03/2011Review Date: 30/03/2013Page 1Version: 5

Part 3Your DeclarationSignaturesI am applying for a Certificate of Compliance as described in thisapplicationI declare that all the information given is true and correctSignatureDateOwners ConsentMust be signed by the owners of the landIf more than one owner, every owner mustsignIf the owner is a Company or Owner’sAssociation, this must be signed by adirector or secretary (or authoriseddelegate) under common sealAs owner(s) of the land to which this application relates, I/we consentto this application. I/we also give consent for authorised Councilofficer or agents to enter (without prior notice) the land to carry outinspections for any buildings, part buildings and pool fencesOwners NameSignatureSignaturePrint Name / AddressPrint Name / AddressPhone NoDateDateIf you are signing on the owner’s behalf as the owner’s legalrepresentative, please state the nature of your legal authority andattach documentary evidence(eg Power of Attorney, Executor, Trustee, Company Director)Your certificate can be either Collected Mailed Faxed DX How to lodge this applicationAddress this application toThe General ManagerCampbelltown City CouncilYou can send it to us by any of thefollowing methodsMailPO Box 57CAMPBELLTOWN NSW 2560Document ExchangeDX5114CAMPBELLTOWN NSWHow to contact usPhone: (02) 4645 4604Fax (02) 4645 4111FeesPlease refer to Council's Fees and Charges located on Council's website: www.campbelltown.nsw.gov.au.Payment MethodsYou can pay by cash, credit card (using the Credit Card AuthorisationForm) or chequeMake cheques payable to ‘Campbelltown City Council’Do not send cash in the mailCourier or Personal DeliveryCouncil OfficeCnr Queen Street & Broughton StreetCAMPBELLTOWN NSWCompliance ServicesDW: 1497733DATA AND DOCUMENT CONTROLRevised Date: 17/03/2011Review Date: 30/03/2013Page 2Version: 5