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Sou0r Stcct
Afnrr*r
Ylhrradrrfie
g59 tED
NorthWarwickshire
BoroughCouncil
Householder
Application
for Planning
Permission
for works
TownandCountryPlanning
Act 1
You can completeand submlt thi3 form electronicallyvia the PlannlngPortal by
Publicatlonof applicationson planningauthoritywebsites
Pleasenote that t{re lnformation provlded on thls applletion form and in supportlng
Authorlvs webslte. lf you require arryfurtfier claifflcatlort please contact the Authorlvs
Please
completeusingblockcapitalsandblackinkIt is lmportantthat you readthe accompanying
guidancenotesasincorrectcompletionwilldelaythe processing
of lour application.
l. Appli(antNameand Address
2, Agent Nameand Address
Title:
Title:
Lastname:
Company
(optional):
Unit
f--_l
I
Company
(optional)r
House
I number:|
Ha.rse[--_l
| suffix |
|
House
name:
Unit
[--l
|
House
| number:|
Housef--_l
| suffix |
n
Address1:
Address2
Address3:
A
Town:
T
County;
C
Country
Postcode
P
3. Descriptionof ProposedWorks
Please
describethe
f,*-?"s-ct
Stg€
+
n-ary\-
'-rwrE., =l-,{al
a'tt}rsir*1s
|
3, Descriptionof ProposedWorks(continued)
Hasthe workalreadystarted?
l_l Yes
_,/
lg|,l{o
./
lfYes,pleasestatewhenthe workwasstarted(DD/MM/YYY$:
Hasthe work alreadybeencompleted?
lYes
!
(datemustbe pre-application
submission
ruo
lf Yes,pleasestatewhenthe workwascompleted(DD/MMAYYY):
4. Site AddressDetails
rand Rightsof Wat
Pedestrianand VehlcleAccess,Roads
Pleaseprovldethe full postaladdressofthe applicationsite.
Unit:
f--_l
|
ttouse
| number:I
(datemustbe preapplicationsubmission)
House f---_l
I suffi* |
|
rlouSe
name:
Address1:
Address2:
ls a newor alteredvehicleaccess
proposedto or from the publichighway?
lYes
6.
ls a newor alteredpedestrianaccess
proposedto or from the publichighway?
! Yes
El.At
Dothe proposals
requireanydiversions,
extinguishments
and/orcreationof public
rightsofway?
flves &
lf Yesto anyquestions,pleaseshowdetailson your plansor
drawingsand statethe referencenumbe(s)ofthe plan(s)/
drawing(s):
Address3:
Town:
County:
Postcode
(optional):
6. Pre-applicationAdvice
7. Treesand Hedges
Hasassistance
or prioradvicebeensoughtfromthe local
./
authorityaboutthisapplication?
pr'r"
Ves
!
Arethereanytreesor hedgeson y(rurown
propertyor on adjoiningpropertieswhich
arewithin fallingdistanceofyour proposed _
development?
L-l Yes
please
po6ition
lfYes,
marktheir
on a scaled
planandstatethe referencenumberofany plansor drawings:
lf Yes,pleasecompletethe followinginformationaboutthe advice
you weregiven.(Thiswill helpthe authorityto dealwith this
applicatlonmoreefficiently).
Pleasetick if the full contactdetailsarenot
known,andthen completeasmuchpossible:
Reference:
Wll anytreesor hedgesneed
to be removedor prunedin
orderto carryout your proposal?
Date(DDMM YYYY):
(mustb€ pre-application
submission)
I ves
lfYes,pleaseshowon your planswhichtreesby givingthem
numberse.9.Tl, T2etc,statethe referencenumberof the plan(s)/
and indicate the scale.
8. Parking
9. Authority Employee/ Member
Willthe proposedworksaffect
existingcarparkingarrangements?
With respectto the Authority,I am:
(a) a memberof staff
(b) an electedmember
(c) relatedto a memberof staff
(d) relatedto an electedmember
I ves
Do anyofthese
statements
applyto yyz
lves
[fn"
providedetailsofthe name,relationship
lfYes,please
androle
1O.Materials
pleasestatewhatmaterialsareto be usedexternally.Includetype,colourandnamefor eachmaterial:
tf ap'plicable,
E(isting
(whereapplicable)
-g
-o
63
Proposed
2=o
krUc-f<-=ozrrt*Walls
Roof
'lw
n
L_A. ffip.,Jn*_ .
Tv
(L,--€
T1\4
y'rrrr-za4 A< tgn,\rq
kj+-ttna
n
lj0vc-.
Windows
u
Doors
n
Boundary
treatments
(e.9.fences,
walls)
n n
Vehicleaccessand
hard-5tanding
n n
Lighting
n n
Others
(pleasespeciff)
n n
Areyou supplyingadditionalinformationon submittedplan(s)/drdwing(s)/design
and accessstaternent?
lfYes,pleasestatereferences
for the
andaccess
State]nent:
! ves
11. OwnershipCertificates
OnecertifiGrt€A. B,C,or D, must be completed,togetherwlth the AgrtculturalHoldlngsCerttfi<ltenraththls appllcatlonforn
- CERTIFICATE
CEFNFICATE
OFOWNERSHIP
A
Town and Country Planning lGeneral Developnent Pro<edurc)Order | 995 Certlficate under Ardde 7
I ceniry/TheaPplicantcenifiesthat on the day2l daysbeforethe dateof thisapplicationnobodyexceptmyself/the applicantwasthe
o\Nnet(owlEriso person.with
a freehold
intercstot leaseholdintercstwith
at leost7yearslefttorun)of anypan of the landor buildingto
whichthe applicationrelates.
Signed- Applicant:
Or signed- Agent:
Date
CERTIFICTTE
OFOWNERSHIPCERTIFICATE
B
bn the da'
7 Wal
DateNotlceServed
Or signed- Agent:
Date(DD/MM/YYYY);
CERNFICATE
OFOWNERSHIP. CERNFrcATEC
Town and Country Plannlng (General Deyelopment Procedurc) Order 1995 Certitlcate undel Anide 7
I certl&/Theapplicantcenifiesthat:
with o freehold
the applicanthas
takenwere:
On thefollowingdate (whichmustnot be earlier
than 2l daysHore the date of the application):
Signed;
Or signed- Agent;
Date (DD/MM/YYYy):
so.t€: 2010{3-r 9 ,5 lRatiff:
2:t53t
(continued)
11. OwnershipCertificates
. CERNFICATE
CERTIFICATE
OFOWNERSHIP
D
Town and CountryPlannlng(GeneralDevelopmentProcedurelOrder 1995Celtiflcateunder Artlde
I certiry/Theapplicantcenifiesthat
-.--
tal(enwere:
Noticeofthe applicationhasbeenpublishedin
(circulatinq
in the areawherethe landis situnG
newsPapel
On the followingdate(whichmustnot be earlier
than 2l daysbeforethe dateofthe application):
Or signed- Agent:
12. AgriculturalLandDeclaration
AGRICULTUMLI.ANDDECLARATION
Town tnd CountryPlanning(GenerallrevelopmentPrccedurelorder1995Ce ificate under A]tlcle 7
- YouMustCompleteEitherA or B
AgriculturalLandDeclaration
(A)Noneofthe landto whichthe applicationrelatesis,or is part of,an agriculturalholding.
Signed- Applicant
Or signed- Agent:
(B)I have/Theapplicanthasgiventhe requisitenoticeto ev
o,on the day 21
beforethe dateot thisapplication,wasa tenantof an agriculturalholdingon all or part of the landto whichthis application
applicatiol
aslistedbelow:
NoticeServed
Or signed- Agent:
- Checklist
13. PlanningApplicationRequirements
DAIE(DD/MM/YYYY)I
-&;
Please
readthefollowingchecklist
to makesureyouhavesentalltheinformation
in supponofyourproposal.Failuretosubmitall
informationrequiredwill resultin your
applicationbeino
informatio4reouir
vour aDDlication
beingdeemedinvalid.lt
ltwill
will not be consideredvalid untilall
until all information
required
the LocafPlanningAuthorityhasbeensubmitted..
//
Theoriginalandi copiesoia
The correct fee:
,lhe originaland3 copiesofa
andaccessstatementif
completedanddatedapplicationform:
Etrl design
proposedwork fallwithina
Theoriginaland
3 copiesofa planwhich
w
d
d
[l*ffi*:;li:ll'*"$Hi$::'r'"
,fl,i.ii1ili&!:t3,'o,,",.,",o"
iiif,iflt.f*18#:-",*'*
icab,e
Listed
Buildins:
E
U/
and
anJito*ingtir"air*ii;;iN;rih,
showingthe directionof North:
Theoriginaland
3 copiesofotherplans
and drawingsor informationnecessary
to
describethe subjenofthe application:
3 copiesofthe
Theoriginaland
7 Certificate
dated.Article
W
14. Declaration
l/wd herebyapplyfor planningpermission/consent
plans/drawings
asdescribedin thisform andthe accompanying
andadditional
information.
Signed - Applicant:
Or signed- Agent:
(datecannotb,
pre-applicatior
15. Applicant ContactDetails
16. Agent ContactOetails
Teleohonenumbers
Telephonenumbers
Country
code:
Extension
Countrycode: Nationalnumber:
number:
Extension
numben
Countrycode:
Country
code:
17. SiteVisit
Canthe rite be seenfrom a publicroad,publicfootpath,bridlewayor otherpublicland?
lf the planningauthorityneedsto makean appointmentto carry
out a sitevisil whom shouldtheycontact?(Please
selectonly
one)
! ngent
pleaseprovide:
lf Otherhasbeenselected,
Contactname:
Teleohonenumben
Emalladdress:
L--l No
rr Other(ffdifferentfromthe
u agenvapplicants
details)