Controlled Burn Application Form for Council-Controlled Road Reserves

Applicant Details

Organisation Name *

Contact Name *

Preferred Contact Number *

Postal Address *

Email Address *

Declaration

I have read and agree to abide by the Standard Conditions for Controlled Burning of Council Road Reserve and declare that the details in this form are correct to the best of my ability. I declare that I am authorised by the property owner/s to undertake controlled burning activities on the property and that only Council road reserves abutting that property will be burned.

Site Details

Street address *

Lot on Plan *

MSC Property Number *

Attach diagram / sketch if required

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Location and name/s of Council road reserves to be burned (attach a diagram or sketch if required *

Insurance Details

If you choose to proceed without the presence of the Rural Fire Brigade you will need to obtain for the period of the burn, public liability cover of at least $20 million with a reputable insurer, noting Council's interest and indemnifying Couincil for all manner of public liabilities associated with this matter.

Name of Insurer

Policy Number

Policy Limit

Expiry Date

Supporting Documentation

Please remember to provide the following supporting documentation when submitting this form.

(Public Liability Insurance required if Rural Fire Brigade will not be present at the controlled burn)

Upload insurance policy

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PRIVACY NOTICE: Mareeba Shire Council is collecting your personal information in accordance with the Local Government Act 2009 in order to process this application. If you choose not to provide your personal information, the application may not be approved. Your personal information will only be accessed by authorised Council employees. Your personal information will not be used for any other purpose or disclosed to any other person or entity unless you have given us permission or we are required by law.Please refer to Council’s QPP Privacy Policy for further information on access or correction of personal information held by Council.

Applicant Signature *

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Captcha *

OFFICE USE ONLY

Approving Officer

Signature

Approval Date

Special Conditions