customer.services@peakdistrict.gov.uk Aldern House 
01629 816200 
                                  - 
                                     Baslow Road 

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APEAK 

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                                  Derbyshire 

I 
        P D I S T R I C T 

NATIONAL PARK AUTHORITY 

Householder Application for Planning Permissi y^^'^WiSrks br extension 

Town and Country Plaijiili^M'TggO 
                                          ^ 

You can complete and submit this form electronically via the Planning Portal by visiting www.planningportal.gov.uk/apply 

## Publication Of Applications On Planning Authority Websites

Please note that the information provided on this application form and in supporting documents may be published on the Authority's website. If you require any further clarification, please contact the Authority's planning department. 

Please complete using block capitals and black ink. It is important that you read the accompanying guidance notes as incorrect completion will delay the processing of your application. 

## 1. Applicant N A M E And Address

Address 3: 
Town: 
County: 
Country: Postcode: 

## 3. Description Of Proposed Works

Please describe the proposed works: 
R.spuAc/Aj<2r ^ ^e/nov//K/^5-) e:xi5T/\;<5- ouTS/oe TOlueT 
BLOCK. 

^DE451AE 
g^J^o 1 b utL mi o a dwelling. 

## 2. Agent Name And Address

House Address 2: 
Address 3: 
Town: 
County: 
Country: 
Postcode: 
SK23 
6B.a~ 

## 3. Description Of Proposed Works (Continued)

|     | Has              |  the work already started?    | Q Yes                           | J / f N o     |
|-----|------------------|-------------------------------|---------------------------------|---------------|
| If  | Yes,             | please                        | state when the work was started | (DD/MM/YYYY): |
| Has | the work already | been                          | completed?                      | j—j y^g       |
| if  | Yes,             | please                        | state when the work             | was           |

## 4. Site Address Details

| Please      |  provide the   |
|-------------|----------------|
| House       | House          |
| Unit:       |                |
| number:     |                |
| suffix:     |                |
| House       |                |
| name:       |                |
| Address     | 1:             |
| Address     | 2:             |
| Address     | 3:             |
| Town:       |                |
| m a n P£AK  |                |
| County:     |                |
| Postcode    |                |
| (optional): |                |

## 6. Pre-Application Advice

| Has                                  |  assistance                            |  or prior                             |  advice                                             |  been sought from the local    |
|--------------------------------------|----------------------------------------|---------------------------------------|-----------------------------------------------------|--------------------------------|
| authority about this application?    | Q Yes                                  | No                                    |                                                     |                                |
| If                                   | Yes,                                   | please                                | complete the following information about the advice |                                |
| you were                             | given.                                 | (This will help the authority to deal | with                                                | this                           |
| application more efficiently).       |                                        |                                       |                                                     |                                |
| Please                               | tick if the                            | full                                  | contact details are not                             |                                |
| known,                               | and then complete                      | as                                    | much                                                | possible:                      |
| Officer name:                        |                                        |                                       |                                                     |                                |
| Reference:                           |                                        |                                       |                                                     |                                |
| Date(DD                              | MM                                     | YYYY):                                |                                                     |                                |
| (must be pre-application submission) |                                        |                                       |                                                     |                                |
| Details                              | of the pre-application advice received |                                       |                                                     |                                |

## 8. Parking Will The Proposed Works Affect Existing Car Parking Arrangements?

| -                                         | Yes    | 0      | No        |
|-------------------------------------------|--------|--------|-----------|
| If                                        | Yes,   | please | describe: |
| (date must be pre-application submission) |        |        |           |
| (date must be pre-applicatron submission) |        |        |           |

## 5. Pedestrian And Vehicle Access, Roads And Rights Of Way

|                                                            | -                                     | Yes    |
|------------------------------------------------------------|---------------------------------------|--------|
| is                                                         | a new or altered vehicle              | access |
| proposed                                                   | to or from the public highway?        |        |
| 0No                                                        |                                       |        |
| -                                                          | Yes                                   |        |
| |7]NO                                                      |                                       |        |
| Is a new or altered pedestrian                             | access                                |        |
| proposed                                                   | to or from the public highway?        |        |
| -                                                          | Yes                                   | 0      |
| Do                                                         | the proposals require any diversions, |        |
| extinguishments and/or creation of public                  |                                       |        |
| rights of                                                  | way?                                  |        |
| If                                                         | Yes                                   | to any |
| drawings and state the reference number(s) of the plan(s)/ |                                       |        |
| drawing{5):                                                |                                       |        |

## 7. Trees And Hedges

| Are                                       |  there any trees or         |  hedges                           |  on your own                                       |
|-------------------------------------------|-----------------------------|-----------------------------------|----------------------------------------------------|
| property or on adjoining properties which |                             |                                   |                                                    |
| are                                       | within                      | falling distance of your proposed |                                                    |
| development?                              |                             | 0                                 | Yes                                                |
| If                                        | Yes,                        | please                            | mark thei,r position on a scaled                   |
| plan and state the reference number of    | any                         | plans or drawings:                |                                                    |
| Will any trees or hedges need             |                             |                                   |                                                    |
| to be removed or pruned in                |                             |                                   |                                                    |
| order                                     | to carry out your proposal? |                                   |                                                    |
| -                                         |                             | Yes                               |                                                    |
| If                                        | Yes,                        | please                            | show on your plans which trees by giving them      |
| numbers                                   | e.g.Tl,                     | T2                                | etc, state the reference number of the plan(s)/    |
| drawing(s) and indicate the               | scale.                      |                                   |                                                    |
| Do                                        | any of                      | these                             |                                                    |
| statements apply to you?                  |                             |                                   |                                                    |
| -                                         | Yes                         | 0                                 | No                                                 |
| 9.                                        | Authority                   | Employee                          | /                                                  |
| With respect to the Authority,            | 1                           | am:                               |                                                    |
| (a) a member of staff                     |                             |                                   |                                                    |
| (b) an elected member                     |                             |                                   |                                                    |
| (c) related to                            | a                           | mem                               | ber                                                |
| (d) related to                            | an                          | elected member                    |                                                    |
| If                                        | Yes,                        | please                            | provide details of the name, relationship and role |

## 10. Materials

If applicable, please state what materials are to be used externally. Include type, colour and name for each material: 

Existing (where applicable) 
Proposed 
Don't 
Know 
Not 
applicable 
hJATuf^AL^ 
S^A/i'-
Walls 
SANOSTOf^^ 
- 
- 
" M v ^ / e o e o w 
" A ^ T / F i c . ( A U 
"i4Ar^oe.os^" S c _ A T e s T O 
/WATCH 
£X.fSr/KJGr 
Roof 
- 
- 
Windows 
- 
- 
Doors 
- 
- 
A5 
BXfST/KJ<^ 
- 
- 
Boundary treatments (e.g. fences, walls) 
Vehicle access and 
hard-standing 
- 
Lighting 
0 
- 
Others (please specify) 
0 
- 
0Yes 
Q N O 
Are you supplying additional information on submitted plan{s)/drawing(s)/design and access statement? If Yes, please state references for the plan(s)/drawing(s)/design and access statement: 
(I 
K 
I' 
Y 2. - 
F L - O O ^ 
P C A N J S ^ 

## 11. Ownership Certificates And Agricultural Land Declaration

One Certificate A, C, or D, must be completed with this application form CERTIFICATE OF OWNERSHIP - CERTIFICATE A 
Town and Country Planning (Development Management Procedure) (England) Order 2010 Certificate under Article 12 
I certify/The applii7:int certifieii that on the day 21 days before the date of this application nobody exceptjajtself/ the applicant was the owner* of any part of the land or building to which the application relates, and that none of the land to which the application relates is, or is part of, an agricultural holding** 
NOTE: You should sign Certificate B, C or D, as appropriate, if you are the sole owner of the land or building to which the application relates but the land is, or is part of, an agricultural holding. 

* "owner" is a person with a freehold interest or leasehold interest with at least 7years left to run. 

** "agricultural holding" has the meaning given by reference to the definition of "agricultural tenant" in section 65(8) of the Act. 

## Certificate Of Ownership - Certificate B Town And Country Planning {Development Management Procedure) (England) Order 2010 Certificate Under Article,

I certify/ The applicant certifies that i have/the applicant has given the requisite notice to everyone else (as listed below) who/on the day 
21 days before the date of this application, was the owner* and/or agricultural tenant** of any part of the land or buildinfyfo which this application relates. 

## 11. Ownership Certificates And Agricultural Land Declaration (Continued) Certificate Of Ownership - Certificate C Town And Country Planning (Development Management Procedure) (England) Order 2010 Certificate Under Article 1:

|                          |                                                            |                                           |                   |        | I certify/The applicant certifies   |  that:               |
|--------------------------|------------------------------------------------------------|-------------------------------------------|-------------------|--------|-------------------------------------|----------------------|
| -                        | Neither Certificate A or                                   | B                                         | can               | be     | issued                              | for this application |
| -                        | All                                                        | reasonable                                | steps have        | been   | taken to                            | find                 |
| the land or              | building,                                                  | or of                                     | a                 | part   | of it, but i have/the applicant     | has                  |
| -                        | "owner" is a person                                        | with a                                    | freehold interest | or     | leasehold interest                  | with at              |
| ** "agricultural tenant" | has the meaning given                                      | in                                        | section 65(8)     | of the | Town                                | and                  |
| The                      | steps taken were:                                          |                                           |                   |        |                                     |                      |
| Name                     | of Owner / Agricultural Tenant                             |                                           |                   |        |                                     |                      |
| Address                  |                                                            | /                                         |                   |        |                                     |                      |
| Date                     | Notice Served                                              |                                           |                   |        |                                     |                      |
| spaper                   |                                                            |                                           |                   |        |                                     |                      |
| On                       | the following date (which must not be earlier              |                                           |                   |        |                                     |                      |
| than                     | 21                                                         | days before the date of the application): |                   |        |                                     |                      |
| Notice                   | of the application has been published in the following ne^ |                                           |                   |        |                                     |                      |
| (circulating in the      | area                                                       | where the land is situated):              |                   |        |                                     |                      |
Date (DD/MM/YYYY): 

## Certificate Of Ownership - Certificate D Town And Country Planning (Devel9Pment Management Procedure) (England) Order 2010 Certificate Under Article 12

I certify/The applicant certifies that: 

|              |                                          |      |                                                |           |                                                    |          | -    | Certificate A cannot be   |    issued |  fo^his application    |
|--------------|------------------------------------------|------|------------------------------------------------|-----------|----------------------------------------------------|----------|------|---------------------------|-----------|------------------------|
| -            | All reasonable steps have beeryxaken to  | find | out the names and                              | addresses | of                                                 | everyone | else | who, on the day           |        21 | days before the        |
| date of this | application,                             | was  | the owner* and/or agricultural tenant** of any | part      | of the land to which this application relates, but |          |      |                           |           |                        |
| have/        | the applicant has beefn unable to do so. |      |                                                |           |                                                    |          |      |                           |           |                        |

* "owner" is a person with a freehold'nterest or leasehold interest with at least 7years left to run. 

** "agricultural tenant" has the n^aning given in section 65(8) of the Town and Country Planning Act 1990 
The steps taken were: 

| Notice              |  of the       |  apoKcation                  |
|---------------------|---------------|------------------------------|
| (circulating in the | area          | where the land is situated): |
| Applicant:          | Or            | signed-Agent:                |
| Date                | (DD/MM/YYYY): |                              |

12. Planning Application Requirements - Checklist Please read the following checklist to make sure you have sent all the information insupport of your proposal. Failure to submit all information required will result in your application being deemed invalid. It will not be considered valid until all information required by the Local Planning Authority has been submitted. 

| The                                          |  original and 3                               |  copies                                   |  of          |  a    |
|----------------------------------------------|-----------------------------------------------|-------------------------------------------|--------------|-------|
| completed and dated application form:        |                                               |                                           |              |       |
| 0                                            |                                               |                                           |              |       |
| The                                          | original and 3 copies of                      | a                                         |              |       |
| design                                       | and                                           | access                                    | statement if |       |
| proposed                                     | works fall                                    | within                                    | a            |       |
| conservation area or                         |                                               |                                           |              |       |
| World Heritage                               | Site,                                         | or relate to a                            |              |       |
| Listed                                       | Building:                                     |                                           |              |       |
| 0                                            |                                               |                                           |              |       |
| 0                                            |                                               |                                           |              |       |
| The                                          | original and 3 copies of                      | a                                         | plan which   |       |
| identifies the land to which the application |                                               |                                           |              |       |
| relates drawn to an identified               | scale                                         |                                           |              |       |
| and                                          | showing the direction of North:               |                                           |              |       |
| The                                          | original and 3 copies of other plans          |                                           |              |       |
| and                                          | drawings or information                       | necessary                                 | to           |       |
| describe                                     | the subjert of the application:               |                                           |              |       |
| 0                                            |                                               |                                           |              |       |
| /                                            |                                               |                                           |              |       |
| /                                            |                                               |                                           |              |       |
| /                                            |                                               |                                           |              |       |
| On                                           | the following date (which must not be earlier |                                           |              |       |
| than                                         | 21                                            | days before the date of the application): |              |       |
| The                                          | correct fee:                                  |                                           |              |       |
| The                                          | original and 3 copies of the                  |                                           |              |       |
| completed,                                   | dated Ownership                               |                                           |              |       |
| Certificate (A,                              | B,                                            | C                                         | or           | D     |
| applicable)                                  | and Article 12                                |                                           |              |       |
| Certificate (Agricultural Holdings):         |                                               |                                           |              |       |
| 0                                            |                                               |                                           |              |       |

13. Declaration l/we hereby apply for planning permission/consent as described in this form and the accompanying plans/drawings and additional information, l/we confirm that, to the best of my/our knowledge, any facts stated are tnje and accurate and any opinions given are the genuine opinions of the person(s) giving them. 

## 14. Applicant Contact Details

number: 

## 16. Site Visit

| Can                                         |  the site be   |  seen         |  from     |  a public            |
|---------------------------------------------|----------------|---------------|-----------|----------------------|
| If the planning                             | authority      | needs to make | an        | appointment to carry |
| out a site visit, whom should they contact? | (Please        | select        | only one) |                      |

## 15. Agent Contact Details

number: 
0No 
Agent 
Applicant 
- 
^
s
X
^