GOVERNMENT INFORMATION
(PUBLIC ACCESS) ACT 2009
MANDATORY DISCLOSURE
PROACTIVE RELEASE
INFORMAL RELEASE
APPLICATION
Please complete this form to apply for information held by Council under the
Government Information
(Public Access) Act 2009 (GIPA Act). If you need help in filling out this form, please contact the Right to
Information Officer on 9840 9840, or visit our website at www.holroyd.nsw.gov.au.
1.
Your Details
Title: Mr / Mrs / Ms
Surname: .........................................................................................................
Other names: .......................................................................................................................................................
Postal address: .....................................................................................................................................................
...............................................................................................................................................................................
Contact number: .................................................................... Facsimile: .........................................................
Email: ..................................................................................................................................................................
Are you seeking personal information? Yes / No
(circle one)
Proof of Identity: .................................................................................................................................................
2.
Type of Information (
Please tick)
1.
Information relating to a property
Street address: …...………………………………………………………………………………………….…..
Lot No: ………………..DP or SP No: ………………Application No: ...…...…………………….……..…....
Description of Building: ..........………………….………………………………………………………………
Approximate age of Building: ..…………………………
Are you the property owner: Yes / No
Please tick the information being sought
DA / CC Application Form
DA, BA or CC Consent
Planner’s report
Plans (site, elevation, shadow, landscape,
section, internal floor) – Copyright consent
Home Owners Warranty Insurance
required
Construction Certificate
Occupation Certificate
Building Certificate
Statement of Environmental Effects
Submissions to DA
Land Contamination Consultant Reports
Office Use Only:
Date application received: .................................................................................... TRIM No: .................................................................
Received by (Officer): ...............................................................................................................................................................................
2
2.
Other Information
Please describe the information you would like to access in enough detail to allow us to identify it.
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
...............................................................................................................................................................................
3.
Penalty Infringement Photographs
Photograph of Infringement No: ....................................................... / Registration No: ……..................
Prior to you being permitted access to this photograph you must provide Council with identification
eg. Drivers Licence, as well as proof of ownership of this vehicle.
3.
Form of Access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify)
...............................................................................................................................................................................
Council endeavours to expedite the release of the requested information, as soon as possible within 20
working days after receipt of the application. Photocopying charges may apply if copies of the relevant
information is requested.
PRIVACY NOTE: Council will collect and hold the personal information contained in this application for
the purpose of processing the application. The intended recipients of the personal information are officers
within Council. The supply of personal information by you is voluntary, however if you cannot provide, or
do not wish to provide the information sought, Council may be unable to process your application.
You may make an application for access or amendments to your personal information held by Council under
the
Privacy and Personal Information Protection Act 1998 (
PPIP Act) or the
Government Information
(Public Access) Act 2009 (
GIPA Act). You may also make a request that Council suppress your personal
information from a public register. Council will consider any such application in accordance with the PPIP
Act.
Information provided to Council in correspondence, submissions or requests, including your personal
information, may be made publicly available, including on Council's website, under the GIPA Act. Please
notify us if you object to the disclosure of your personal information.
Please email, fax, post or lodge this form at:
Cumberland Council
16 Memorial Avenue
Merrylands NSW 2160
PO Box 42
Merrylands NSW 2160
Fax: 9840 9734
Email: xxxxxxx@xxxxxxxxxx.xxx.xxx.xx
