APPLICATION FOR PERMIT TO CARRY OUT
WORKS OR ACTIVITIES TO A HERITAGE PLACE
OR HERITAGE OBJECT
Pursuant to Section 67 of the Heritage Act 1995
Heritage Victoria
Phone: 136186
Email: heritage.victoria@delwp.vic.gov.au
Web: www.heritage.vic.gov.au
Questions marked with an asterisk (*) are mandatory and must be completed. Incomplete applications will be
returned to the applicant.
Instructions to complete form
Preliminary information
This application form is a legal document. It MUST be completed and read in conjunction with the associated document
“Instructions for Completing an Application for Permit to Carry out Works or Activities to a Heritage Place or Heritage Object”. By
completing this application form, all signatories are taken to have read the associated document and understood the manner in
which the information in this application form may be used in the future.
ALL SECTIONS MUST BE COMPLETED. Incomplete applications will be returned to the applicant and result in delay. It is the
applicant’s responsibility to ensure that the full and correct information is provided. Applications made on behalf of business
names or unincorporated associations also require an individual applicant’s name, e.g. Ms Jane Smith, Capital Enterprises Pty
Ltd.
Who should complete this form?
A person wanting to make an application for a permit to carry out works or activities to a place or object included in the Victorian
Heritage Register.
Please attach a signed Statement of Consent (see last page of this form) if the applicant is not the owner.
Applicant details
Name
The person who wants the permit
Title*
Surname*
Given name*
Business details
ABN Australian Business Number
ACN Australian Company Number
Business/Organisation name
Address
Street address/Postal address*
Suburb/Town*
State*
Postcode*
Phone and email
Business phone*
Email*
Mobile/alternative phone number*
(0 )
1
Contact person details
Same as above (double click to check box if completing electronically)
Name
The person you want Heritage Victoria to communicate with about the application
Title*
Surname*
Given name*
Business details
ABN Australian Business Number
ACN Australian Company Number
Business/Organisation name
Address
Street address/Postal address*
Suburb/Town*
State*
Postcode*
Phone and email
Business phone*
Email*
Mobile/alternative phone number*
(0 )
Owner details
Name
The person or organisation that owns the heritage place or object
Title*
Surname*
Given name*
Applications made on behalf of organisations also require an individual applicant’s name
Business details
Business/organisation name
ACN Australian Company Number
Address
Street address/Postal address*
Suburb/Town*
State*
Postcode*
Phone number*
Heritage place or object details
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Heritage place or object name*
Victorian Heritage Register number*
Each place and object on the Victorian Heritage Register has a unique number beginning with H and followed by 4 digits. If you
do not know the number you can look it up on the Victorian Heritage Database at: http://vhd.heritagecouncil.vic.gov.au/.
Address/Location
Street address/location description*
Suburb/Town*
Land title for heritage place
Current title/s attached?* (double click to check box if completing electronically)
Cultural Heritage Management Plan
A Cultural Heritage Management Plan (CHMP) is a written report, prepared by a Cultural Heritage Advisor, containing the results
of an assessment of the potential impact of the proposed activity on Aboriginal cultural heritage. Heritage Victoria is not able to
issue statutory approvals without first receiving an approved Cultural Heritage Management Plan if one is required.
1.
Is a CHMP required under the Aboriginal Heritage Act 2006 for the proposed works?*
Yes (go to question 2)
No (go to question 4)
See the Instructions for guidance on determining whether a CHMP is required for the proposed works.
2. Has a CHMP been approved for proposed works?*
Yes (go to question 3)
If a CHMP has been approved, the approval letter and CHMP must be attached.
3.
Do the proposed works contravene the approved CHMP?*
question 4)
4.
Do the proposed works contravene any previously approved CHMPs?*
No (Please contact Heritage Victoria)
Yes (please contact Heritage Victoria)
No (go to
Yes (please contact Heritage Victoria)
No
The applicant must disclose whether a CHMP is required under the Aboriginal Heritage Act 2006. If a CHMP is required,
Heritage Victoria must not grant a permit until a CHMP has been approved (see section 52(1) of the Aboriginal Heritage Act
2006). Under section 52(4) of the Aboriginal Heritage Act 2006, the time required for Heritage Victoria to make a permit decision
is deemed not to have commenced until a copy of an approved CHMP is provided.
Applicants can use the Aboriginal Heritage Planning tool to determine whether a CHMP is required:
http://www.dpc.vic.gov.au/index.php/aboriginal-affairs/heritage-tools/25-aboriginal-affairs/452-aboriginal-heritage-planning-tool
Further information on CHMPs and the Aboriginal Heritage Act 2006 is available at:
http://www.dpc.vic.gov.au/index.php/aboriginal-affairs/aboriginal-cultural-heritage/cultural-heritage-management-plans
Description and reason for proposed works
Description*
Please include a brief description, even if you are attaching further information.
Supporting documentation fully detailing the proposed works MUST be attached to this application. Please see “Checklist of
documentation required for a heritage permit application” for the documentation that must be provided.
Do the works involve common property?*
Yes
No (double click to check box if completing electronically)
If YES, written consent of the Chair of the Body Corporate must be obtained and attached to this application.
Estimated cost of works*
$
Supporting documents
The following supporting documents must be submitted with this application:
A current copy of title
The current copy of all relevant titles must be dated within 30 days of the date this application is lodged.
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Approved Cultural Heritage Management Plan
Attach approved CHMP, if required.
Full details of the proposed works
All documents specified under the relevant category of works shown in the “Checklist of documentation required for a heritage
permit application” MUST be included with this application (see http://www.dpcd.vic.gov.au/heritage/permits/how-to-apply-for-apermit).
Consent of the Chair of the Body Corporate
Attach if works are proposed for common property.
IT IS RECOMMENDED THAT ALL SUPPORTING DOCUMENTS BE PROVIDED IN PDF OR WORD ELECTRONIC FORMAT.
Permit fee
Class of application*
Class
Permit fee to be paid*
$
How to determine the required permit fee:
Please refer to the permit fees page for assistance in determining the required fee. Please contact Heritage Victoria if you require
further assistance.
Applicant Declaration
I am the Applicant. I declare that the information supplied in this application is accurate and correct. I authorise officers
appointed by the Executive Director or any member of the Heritage Council to inspect the heritage place or heritage object to
assess this application, and to carry out any further inspections required during the time the approved works are being
undertaken or within 6 months of notification of their completion. I undertake that the works/activities will be carried out in
conformity with permits granted by the Executive Director and understand that it is a criminal offence to undertake works to the
heritage place or heritage object not in accordance with a permit.
Name of Applicant*
Signature of Applicant*
Date*
DD/MM/YYYY
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Owner Declaration
Heritage Act 1995
Heritage (General) Regulations 2005
Consent of owner under section 67 to an application for a permit to carry out works or activities in relation to a registered place or
object.
Statement of consent by owner*:
I am the owner of the registered place/registered object described in the permit application dated…………….(insert date) and I
hereby consent to the application to carry out the works or activities specified in the application.
Name/Business Name*
Applications made on behalf of organisations also require an individual applicant’s name
Address*
Signature*
Date*
DD/MM/YYYY
Note: The name supplied above should match the details contained in the Certificate of Title.
Government Owner Declaration
Is the heritage place or heritage object government owned?*
Yes
No (double click to check box)
If yes, a government authorised person must complete the following owner declaration.
I am the owner of the registered place/registered object described in the permit application and I hereby consent to the application
to carry out the works or activities specified in the application.
Name*
Position and Department/Agency*
Signature*
Date*
DD/MM/YYYY
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Privacy statement
Any personal information about you or a third party in your correspondence will be protected under the provisions of the Privacy and Data
Protection Act 2014. It will only be used or disclosed to appropriate Ministerial, Statutory Authority, or departmental staff in regard to the
purpose for which it was provided, unless required or authorised by law. Enquiries about access to information about you held by the
Department should be directed to the Privacy Coordinator, Department of Environment, Land, Water & Planning, PO Box 500, East
Melbourne, VIC 8002.
Notwithstanding the above, please note that information provided to enable the administration of the Heritage Act 1995 may be disclosed
to persons with an interest in the heritage place or object particularly, and information provided as part of a permit applic ation may be
made available on-line where the application has been publicly advertised under section 68 of the Heritage Act 1995.
Payment Options: (Please retain Receipt for future reference)
Cheque payment can be made at your Local Australia post outlet
Any dishonored Cheque will incur a fee of $110.00
BPAY Biller Code: 72637
Customer Ref: 164123456786
Telephone & Internet banking BPay, Contact your bank or
financial institution to make this payment from your cheque,
savings, debit, credit card or transaction account.
More info: www.bpay.com.au
By Cash, Cheque or Debit Card only
Please record payment details below (Application will not be processed without accurate payment details)
BPAY(please tick) 
Australia post (please tick) 
Amount Paid*
Amount Paid*
Your Bank Name*
Unique Sequence No*
(see sample of Australia Post receipt)
Payment method*
Receipt No*
Cash /Cheque /Card (please circle)
Receipt Date*
Receipt Date*
Lodgement
Please lodge your application in one of the following ways:
By email to heritage.permits@delwp.vic.gov.au
OR
By post to: Heritage Permits Coordinator, Heritage Victoria, PO Box 500, MELBOURNE VIC 8002
Office use only
Application no.
Date received
Log on
Date expires
Payment method
Fee received?
YES
NO
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