APPLICATION FOR REPORT AND CONSENT
Application fee is $250.60
Important: (please note if the below is not provided your application WILL be returned.)
 Two copies of the plans & elevations to be submitted (applies to hard copies only)
 For siting variations an assessment against the relevant parts of the Minister’s Guideline is to
be submitted with the application.
 Current Copy of Title must be attached to the application.
 Application Fee Attached
Applicant Details
Name: …………………………………………………………………………………………………………………
Address: ………………………………………………………………………………………………………………
Post Code: …………….....
E-mail: …………………...................................................................................
Phone number: ……………………………
Mobile: ………………………
Report and consent response preferred by:  Email
 Post
Fax: …….………………………
Fax
Property Details
Address: ………………………………………………………………………………………………………………
Volume: …………… Folio: ………… Lot Number: ………Plan of Subdivision No: ………..…………………
Registered owner: ……………………………………………………………………………………….................
Type of Request
Please tick and write below:
 Siting variation (Part 4 of Building Regulations 2006)
 Projection over the street alignment (Part 5, Division 2 of the Building Regulations 2006)
 Protection of the public (Regulation 604 of the Building Regulations 2006)
Description: ……………………………………………………………………………………………………….......
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Signature: ………………………………………………………………………. Dated: …………………………..
Credit Card Payments
Visa
MasterCard
Card No: …………………………………..
Cardholder name: ……………………………………….....
Expiry Date: ………… ..
Cardholder Signature: ………………………....
Further Information
Tel: (+61 3) 5662 9200
Fax: (+61 3) 5662 3754
E-mail: council@southgippsland.vic.gov.au
Postal Address: Private Bag 4, Leongatha, Victoria, 3953 Street Address: 9 Smith Street, Leongatha
Privacy statement
The information requested on this form is being collected by Council for the purpose of processing the request for information application. The
information will be used solely by Council for that primary purpose or directly related purposes.
Revised Sept 2013