Applicant Name
Contact Name (if different to above)
Postal Address
Postal Address
Street Name
Suburb
State
-- Select an option --
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Phone Number
Email Address
Subdivision Approval Details
Subdivision Approval Details
Landowner Name
Is the property address the same as the Applicant address?
-- Select an option --
Yes
No
Property Address
Property Address
Street
Suburb
State
-- Select an option --
WA
Postcode
WAPC/Agency Approval Number
Date of WAPC/Agency Approval
Enter a date in the DD/MM/YYYY format.
Plan Number
Number of Stages
Number of Stages
Statement of Compliance
Statement of Compliance
Choose how many conditions are applicable to this clearance
-- Select an option --
0
1
2
3
4
5
6
1. Condition Number
Description of Condition
Include description of condition (e.g. S150, 70A, noise wall, anti-graffiti, paint etc)
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
2. Condition Number
Description of Condition
Include description of condition (e.g. S150, 70A, noise wall, anti-graffiti, paint etc)
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
3. Condition Number
Description of Condition
Include description of condition (e.g. S150, 70A, noise wall, anti-graffiti, paint etc)
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
4. Condition Number
Description of Condition
Include description of condition (e.g. S150, 70A, noise wall, anti-graffiti, paint etc)
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
5. Condition Number
Description of Condition
Include description of condition (e.g. S150, 70A, noise wall, anti-graffiti, paint etc)
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
6. Condition Number
Description of Condition
Action Taken
Include evidence, dates, plans, site photos, Main Roads specification numbers, correspondence, paint brands and proprietary name etc. Note reference to attachments OR note where a condition is not applicable to a stage and justify
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Full Name
Enter name of person accepting above declaration
