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

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