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Cnr Campbell & Vulcan St
PO Box 99 MORUYA NSW2537 Telephone: 02 4474 1000
Facsimile: 02 4474 1234 E: [email protected]
www.esc.nsw.gov.au
FORM 3 – SURRENDER OF CONSENT GRANTED UNDER THE
ENVIRONMENTAL PLANNING ASSESSMENT ACT 1979 In accordance with Clause 4.63 Environmental Planning & Assessment Act 1979 and Clause 97
Environmental Planning and Assessment Regulation 2000
OWNER(S) OF THE LAND
Owner’s name(s):
Postal address:
Postcode: Phone: Mobile:
Email address:
PROPERTY TO WHICH THE CONSENT RELATES TO
No: Street/Road:
Town: Lot no.: Deposited/Strata Plan:
DEVELOPMENT APPLICATION INFORMATION
Development Application (DA) number: Date of determination:
Description of approved consent:
If development has commenced, describe extent of works carried out:
The surrender will not have an adverse impact on any third party or the locality: Yes No
APPLICANT’S SIGNATURE
Applicant’s name:
Signature:
Date:
OWNER’S SIGNATURE
Owner’s name(s):
Signature(s): Date:
