w\i$^/northwarksgov ulJplanning
Teli018277153{1
uk
Emall:planningcontrol@northwarks-gov.
oi_ar:,!'i::r
I
The CouncllHouse
South Street
Ather6tone
Warwi.kshire
CVglDE
NorthWarwickshi
Borough
Council
to a dwelling
orksor extension
TownandCountry
Planning
Act1990
Householder
Application
fo
You cen completeand submit thls folm electroni(ally via the Plannlng Portal by visiting wurw.plannlngportal.gov.uUapply
Publicationof applicationson planningauthority websiteJ
Please
note that the Informationprovldedon this applicationform and in supportingdocumentsmay be publishedon the
lutho]ity's websile. lf you require any further clarification,pleasecontact the Authority's pl.nning department,
)leasecompleteusingblockcapitals
andblackink.
t is importantthatyou readthe accompanying
guidancenotesasincorrect
ofyourapplication.
completionwilldelaythe processing
L ApplicantNameand Address
Tirle:
Title:
altdri"'nu'u'F-----l
Lastname:
[-l
K*Oa<
lFirstname:l
O' rar.'ro.-,e-r'\'
ffm,,f qo
-l
Company
(optional): Pocvv.r
il,"#i:
[-l
House
name:
Unit:
r-r.r.^, -{1g
e g41, 611 -
f----_-l li"#i:
[ + l is,l'r".
I
House
name:
Cc u<-e,u r.-r-
Addressl:
'l: -TarDe^JT
Address
Ra*t>
Address
2i
Address
2:
Address
3:
Address
3:
Town:
l-rATet'?-
County:
6,P-.
OZTo'<
trr./CHAryt
Country:
Hc,l-rrz.tq^..r
Town:
hJLrN€-A-Tor^J
County:
1,{Ae(S
Country:
Postcode:
B+t-
tR-D.
Postcode:
3. Descriptionof ProposedWorks
Please
describe
the proposedworks:
e:k
I UeS
Jor..l€s
Company
(optional):
Unit:
2. Agent Nameand Address
Terzr..rAL
t^vA Ll-
J^1
gerr{-Tto,\,
Cvtt
t+ P'v
BLr3 | FJ€S.S
t^.JA:/
t. DescnPtion ol ProPosed
works lcontanued,
! ves d^.
las the workalready
started?
I
f Yes,pleasestatewhenthe work wasstarted(DD/MM/YYYY):
las th€ workalreadybeencompleted?
! Yes ffio
f Yes,oleasestatewhenthe workwascompleted(DD/MM/YYYY):
4. SiteAddressDetails
-l
tleaseprovidethefull postaladdress
of the application
site.
Unit:
f-l
ffit* foo
ii,'#i:
[-l
House
name:
A<.:'P.D
C6r-e.SFrru--
(datemustbe pre-application
submission
(datemustbe pre-application
submission)
Roadsand Rightsof Wa)
and VehicleAccess,
5. Pedestrian
vehicle
access
lsa neworaltered
proposedto or fromthe publichighway?
! ves Bruo
ls a new or alteredpedestrianaccess
proposedto or fiom the publichighway?
! ves
requireanydiversions,
Oothe proposals
and/or
creationof public
extinguishments
rightsof way?
! ves [ftuo
Eflno
pleaseshowdetailson yourplansor
lf Yesto anyquestions,
numbe(s)ofthe plan(s)/
state
the
reference
drawings
and
drawing(s):
V\J ^ae!Z_
County:
Postcode
(optional):
o e_-T6.-J -
@ r4ra,r./
8r+t-
C r' Arua
| 2D.
Advice
6. Pre-application
7. Treesand Hedges
las assistance
or prior advicebeen sought from the local
ruthorityabout this application?
l-l yes
Are there any treesor hedgeson your own
property or on adjoining properties which
are within fallingdistanceof your proposed _
development?
L-l Yes
f Yes,pleasecompletethe followinginformation
aboutthe advice
will
help
the
authority
to
deal
with this
were
/ou
9iven.Ohis
mor€efficiently).
rpplication
)leasetickif thefull contactdetailsarenot
<nown,andthencompleteasmuchpossible:
lf Yes.pleasemarktheirpositionon a scaled
planandstatethe r€ference
numberof anyplansor dtawings:
Officername:
DAIE(DDMM YYYY):
submission)
.mustbe pre-application
Willanytreesor hedgesneed
to be removedor orunedin
orderto carryout yourproposal?
lf Yes,pleaseshowon yourplanswhichtleesby givingthem
numberofthe plan(s)/
numberse.g.T'1,T2etc,statethe reference
drawinq(s)and indicatethe scale.
B, Parking
9. Authority Employee/ Member
flill the proposedworksaffect
rxistingcarparkingarrangements?
I am:
Withrespectto the Authority,
(a) a memberof staff
(b) an electedmember
(c) relatedto a memberof staff
(d) felatedto an electedmembel
Doanyof these
statements
applyto you?
!
ves
W"
lf Yes,pleaseprovidedetailsof the name,relationshipand role
I o. Materials
f applicable,pleasestatewhat materialsare to be used externally.Includetype, colourand name for each material:
Don't
Know
Existing
(whereapplicable)
--Fe-AD,.1,
Walls
-T€.-rucEo
c'v Ar-
8..;ru!
R-el'.roeze.D
f,
,_t r g,A
Roof
Windows
Doors
treatments
Boundary
(e.9.fences,
walls)
Vehicleaccess
and
hard-standing
Lighting
Others
(pleasespeci!)
statement?
andaccess
additionalinformation
on submittedplan(s)/drawing(s)/design
Areyou supplying
for the planG)/drawinq(s)/design
andaccess
statement:
lf Yes,pleasestatereferences
Dto
I l. 9wnership certiticates
OneCertlficateA, B,C,or D, must be completed,togetherwlth th€ AgriculturalHoldingsCertificatewith this appllc.tlontorm
- CERTIFICATE
A
OFOWNERSHIP
CERTIFICATE
ManagementProcedure)(England)Order2010CertiflcateunderArtlcle12
Town and CountryPlanning(Development
wasthe
nobodyexceptmyself/the applicanl
that;n the dai 21 daysbeforethe dateof thisapplication
I certiry/The
applicantce;tifies
)wnet'(ownetis o personwitha freeholdintereitor leaiehotdintercstwithot leoslTyea$ leftto run)of any part of the landor buildingto
/vhichthe application
relates.
DAIC(DDlMM/YYYY):
Signed- Applicant:
CER
Managem.ntPro(edure)(England)Order2010Certifi(ateunder Article12
fown and CountryPlanning(Devetopment
else(aslistedbelow)who,on the da)
I certify/Theapplicantc6rtifies
tha-tI have/tlieapplicanthis giventhe requisitenoticeto everyone
pplication,was
ot leaseholdinterestwithat leost7 yeat:
was the owner
owne lowneris o personwith o freeholdinterest
daysbe{ore
be{orethe date
date
te of tthis
this
application,
hisa
llfl dayi
relates.
eft to run)of
of the land or buildinq to which this
Date Notice SeNed
Nameof Owner
Signed- Applicant:
or signed- Agent:
Date(DD/MM/YYYY):
C
OFOWI{ERSHIP- CERTIFICATE
CERTIFICATE
ManagcmentPro(edure)(EnglandlOrd€12010Certiticateundel Atiicle 12
Town and CountryPlanning(Development
certify/Theapplicanlcertifiesthat:
.
NeitherCertificate
A or B canbe issuedfor thisapplication
.
of the otherowners(ownetis o pe6onwith.ofrcehold
All reasonable
stepshavebeentakento find out the namesand addresses
intercstwithot least7yeotsleft to run)ol the landor building,or of a part of it , bul I have/the applicanlhas
interest
or leasehoid
been unablelo do so.
hasbeenpublishedin the followingnewspaper
Noticeof the application
in the areawherethe landis
Signed- Applicant:
Or signed- Agent:
,,1
On thefollowingdate(whichmustnot beearlier
than2 l daysbeforethe dateof the application):
DAIE(DD/MM/YYYY):
I 1 . Ownershap Certiticates lcontinued,
. CERTIFICATE
D
CERTIFICATE
OFOWNERSHIP
ManagementProcedure)(England)Order20l O(ertificateunderArti(le 12
Town and CountryPlanning(Development
that:
I certiry/Theapplicanlcertifies
.
for thisapplication
Certificate
A cannotbe issued
beforethe .
on the day21 d_ays
.
€lse.who,
of everyone
All reaso
nable stepshavebeentaken t6 iind out the namesandaddresses
intetestwi.thot leost7yeor leftto run)
dat€ of this application,wasthe owne| (ownetisa pe$onwitha frceholdintercstot leosehold
r€iates,
but I have/the applicanthasbeenunableio do so.
of anypartoi ihe landto whichthisapplication
hasb€€npublishedin the followingnewspaper
Noticeof the application
(circulatinq
in the areawherethe landis situated):
Onthe followingdat€(whichmustnot be earlier
than2| daysbeforethe dat€of the appli(ation):
DAtE(DD/MM/YYYY)
Or signed- Agent:
Signed- Applicant:
I
t||l
12. AgliculturalLandDeclaration
AGRICULTURAL
LANDDECLARATION
Townand CountryPlanning(DevelopmentManagementProcedurel(England)Order20r 0 CertificateunderArticlel2
- YouMustComPl€te
EitherA or B
Declaration
AgricultulalLand
(A)Noneof the landto whichthe application
holding.
lelatesis,oI is partol an agricultural
DAIE(DD/MM/YYYY
who,onthe day21 daYs
(B)| have/Theapplicanthasgiventhe requisite
noticeto everypersonotherthanmyself/theapplicant
relates,
biforethe datebi thisapplicition,wasa ienantof an agriculturilholdingon all or partof the landto whichthisapplication
aslistedbelow:
DateNoticeServed
Or signed- Agent:
Signed- Applicant:
t
Date(DD/MM/YYYY
rl
il
- Checklist
13. PlanningApplicationRequirements
to submitall
in supportof yourproposal.Failure
to makesureyou havesentallthe information
Please
readthe followingchecklist
required
information
requit by
untilall information
validuntil
not be
be considered
consideredvalid
yourapplicatiol
will not
invalid. lt will
resultin your
wiii result
applicatidn
beingdeemedinvalid.
required
requiredwill
information
information
the LocalPlanningAuthority hasbeen submitted.
ofr a The
lhe o
original
r l g l n aa
and
l n d J3 ccopies
o p l e so
T h eo r i q i n a la n d 3 c o p i e s o f a
form:
anooatedapplication
compteieJ
!
Theoriginaland3 copiesof a planwhich
identifies
the landto whichtheapplication
relates
drawnto an identifiedscale
n
andshowingthe directionof North'
plans
Theoriginaland3 copiesof other
necessary
to
anddrawingsor information
th6subjectofthe application: l-l
describe
Thecorrectfee:
if
!::iglll9.:_._l:l:;tat€m_ent
proposed
worksfallwithina
conservationareaor
WorldHeritage
Site,or relateto a
ListedBuilding:
T-J
tr
Theorioinaland3 copiesof the
comoleied,datedOwnershiP
tr-.1
(A,B,C or D -asapplicable):u
Certificate
Theoriginaland3 copiesofthe
l2 Certificate
compleled,da.ted.Article
n
| 4. Declaration
plans/drawinqs
andadditional
in thisformandthe accompanying
asdescribed
/we herebyapplyfor planningpermission/consent
,
nformation.t/we corifirmthatl io the bestof my/our knowledge,anyfactsstatedaretrue andaccurateand any opinionsgivenarethe
givingthem.
Jenuineopinipnsofthe person(s)
DAIE(DD/MM/YYYY):
(datecannotb(
pre-application
I q, lr f z",'z
t 5. ApplicantContactDetails
16. Agent ContactDetails
Telephonenumbers
numbers
Telephone
Extension
:lHtt#^
code: Narionat
country
number:
8".;@
Countrycode: Mobilenumber(optional):
countrycode: Faxnumber(optional):
(optional):
Emailaddress
d.Clrv'r i-. C2 locvv-Ja'lv1
t 7, Site Visit
-/
Co'
el'
:an the sitebe seenfrom a publicroad,publicfootpath,bridlewayor other publicland? f:l{es
E"o
f the planningauthorityneedsto makean appointmentto (arry
Other(if differentfrom the
selectonlyone)
! npplicanttr agent/applicant's
{es"nt
)ut a sitevisit,whomshouldthey contacl?(Pleose
details)
fOther hasbeenselected,pleaseprovide:
number:
TeleDhone
Contactname:
l{ *a-e'=r
cl ^,^ AzA
Emaifaddress:I o.d.r' ir. @ r ocv "-)a / 'Y1
O2\}-?(-
3+SSStJ-'