Lisburn Online Forms - Cooling Towers Application

Title:

First Name(s):

Surname:

Email:

Telephone Number:

+

Fax Number:

Other Telephone Number:

+

Are you an agent acting on behalf of the applicant?:

YesNo

Are you:

Applying as a business or organisation, including as a sole trader
Applying as an individual

Is your business registered in the UK with Companies House?:

YesNo

Is your business registered outside the UK?:

YesNo

Commercial register:

Registration Number:

Business Name:

Vat number:

Legal status:

Your position in the business:

Building number or name:

Street:

City or Town:

County:

Postcode:

Country:

Please indicate whether this is a:

New notificationNotification with a change of details

Name of premises/trading name:

Is the address the same as (or similar to) the address given in section one?:

YesNo

Building number or name:

Street:

City or town:

County:

Postcode:

Country:

Are the contact details the same as (or similar to) the contact details given in Section 1?:

YesNo

Email:

Telephone Number:

+

Other telephone number:

+

Main activity of business:

Total in use:

Total not in use:

Total in use:

Total not in use:

Device 1 - Site Reference Number:

Type of Device:

Cooling Tower
Evaporative Condenser

Status of device:

New device
Already operational
Decommissioned
Recommissioned

Details of device - make, model, serial number, whether induced or forced, etc:

Location of device (e.g.north works, main buidling, SE corner of 3rd floor roof and/or OS map reference and any additional details):

Device 2 - Site Reference Number:

Type of Device:

Cooling Tower
Evaporative Condenser

Status of Device (No 2):

New device
Already operational
Decommissioned
Recommissioned

Details of device - make, model, serial number, whether induced or forced, etc:

Loction of devide (e.g. north works, main buildnig, SE corner of 3rd floor roof and/or OS map reference and any additional details):

Devise 3 - Site Reference Number:

Type of device (no 3):

Cooling Tower
Evaporative Condenser

Status of device (no 3):

New device
Already operational
Decommissioned
Recommissioned

Details of device - make, model, serial number, whether induced or forced, etc:

Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):

Devise 4 - Site Reference Number:

Type of Device (No 4):

Cooling Tower
Evaporative Condenser

Status of Device (no 4):

New device
Already operational
Decommissioned
Recommissioned

Details of device - make, model, serial number, whether induced or forced, etc:

Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):

Devise 5 - Site Reference Number:

Type of Device (No 5):

Cooling Tower
Evaporative Condenser

Status of Device (No 5):

New device
Already operational
Decommissioned
Recommissioned

Details of device - make, model, serial number, whether induced or forced. etc:

Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):

First name(s):

Surname:

Position/job title:

Is the address the same as (or similar to) the address givenn in Section 1?:

YesNo

Buildling number or name:

Street:

City or town:

County:

Postcode:

Country:

Are the contact details the same as (or similar to) the contact details given in section1?:

YesNo

Email:

Telephone number:

+

Other telephone number:

+

Are the contact details the same as (or similar to) the contact details given in section 1?:

YesNo

Email:

Telephone No:

+

Other telephone number:

+

Remove this persons details:

2nd person - First Name(s):

Surname:

Position/job title:

Is the address the same as (or similar to) the address given in section 1?:

YesNo

Building number or name:

Street:

City or town:

County:

Postcode:

Country:

Are the contact details the same as (or similar to) the contact details given in section 1?:

YesNo

Email:

Telephone Number:

+

Other telephone number:

+

Are the details the same as (or similar to) the contact details given in section 1?:

YesNo

Email:

Telephone number:

+

Other telephone number:

+

Remove this persons details:

Add another persons details:

Does a different person have responsibility for the notifiable devices?:

YesNo

First name(s):

Surname:

Position/job title:

Is the address the same as (or similar to) the address given in section 1?:

Yes
No

Building number or name:

Street:

City or Town:

County:

Postcode:

Country:

Are the contact details the same as (or similar to) the contact details given in section one?:

Yes
No

Email:

Telephone number:

+

Other telephone number:

+

Are the contact details the same as (or similar to) the contact details given in section 1?:

YesNo

Email:

Telephone Number:

+

Other telephone number:

+

Remove this persons details:

Add another persons details:

Please check local guidance notes and conditons for any additional information which may be required:

I hereby apply to Lisburn City council pursuant to:

I would confirm that the details that I have given are correct

Full name:

Date:

Digital Signature:

Section 1 of 7
Applicant Profile
Title:
First Name(s):
Surname:
Contact Details
Email:
Telephone Number:	+
Fax Number:
Other Telephone Number:	+
Are you an agent acting on behalf of the applicant?:	YesNo
Are you:	Applying as a business or organisation, including as a sole trader Applying as an individual
Your Business
Is your business registered in the UK with Companies House?:	YesNo
Is your business registered outside the UK?:	YesNo
Commercial register:
Registration Number:
Business Name:
Vat number:
Legal status:
Your position in the business:
Address
Building number or name:
Street:
City or Town:
County:
Postcode:
Country:
Section 2 of 7
Type of Notification
Please indicate whether this is a:	New notificationNotification with a change of details
Address where the Cooling Towers/Evaporators are Situated
Name of premises/trading name:
Is the address the same as (or similar to) the address given in section one?:	YesNo
Building number or name:
Street:
City or town:
County:
Postcode:
Country:
Contact Details (if different)
Are the contact details the same as (or similar to) the contact details given in Section 1?:	YesNo
Email:
Telephone Number:	+
Other telephone number:	+
Main activity of business:
Section 3 of 7
Details of All Cooling Towers and Evaporative Condensers at this Address
Please provide details about the total number of notifiable devices at this address
Cooling Towers
Total in use:
Total not in use:
Evaporative Condensers
Total in use:
Total not in use:
Please Provide Details about EACH Individual Notifiable Device
Device 1 - Site Reference Number:
Type of Device:	Cooling Tower Evaporative Condenser
Status of device:	New device Already operational Decommissioned Recommissioned
Details of device - make, model, serial number, whether induced or forced, etc:
Location of device (e.g.north works, main buidling, SE corner of 3rd floor roof and/or OS map reference and any additional details):
Device 2 - Site Reference Number:
Type of Device:	Cooling Tower Evaporative Condenser
Status of Device (No 2):	New device Already operational Decommissioned Recommissioned
Details of device - make, model, serial number, whether induced or forced, etc:
Loction of devide (e.g. north works, main buildnig, SE corner of 3rd floor roof and/or OS map reference and any additional details):
Devise 3 - Site Reference Number:
Type of device (no 3):	Cooling Tower Evaporative Condenser
Status of device (no 3):	New device Already operational Decommissioned Recommissioned
Details of device - make, model, serial number, whether induced or forced, etc:
Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):
Devise 4 - Site Reference Number:
Type of Device (No 4):	Cooling Tower Evaporative Condenser
Status of Device (no 4):	New device Already operational Decommissioned Recommissioned
Details of device - make, model, serial number, whether induced or forced, etc:
Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):
Devise 5 - Site Reference Number:
Type of Device (No 5):	Cooling Tower Evaporative Condenser
Status of Device (No 5):	New device Already operational Decommissioned Recommissioned
Details of device - make, model, serial number, whether induced or forced. etc:
Location of device (e.g. north works, main building, SE corner of 3rd floor roof and/or OS map reference and any additional details):
Section 4 of 7
Person in Control of Access to the Premises
Please record details of the person or people who are in control of access to the premises - out of hours contact details must be included, in order that access can be gained at ANY time
First name(s):
Surname:
Position/job title:
Address1
Is the address the same as (or similar to) the address givenn in Section 1?:	YesNo
Buildling number or name:
Street:
City or town:
County:
Postcode:
Country:
Contact Details - (if different)
Are the contact details the same as (or similar to) the contact details given in section1?:	YesNo
Email:
Telephone number:	+
Other telephone number:	+
Contact details - if different
Are the contact details the same as (or similar to) the contact details given in section 1?:	YesNo
Email:
Telephone No:	+
Other telephone number:	+
Remove this persons details:
2nd person - First Name(s):
Surname:
Position/job title:
Address
Is the address the same as (or similar to) the address given in section 1?:	YesNo
Building number or name:
Street:
City or town:
County:
Postcode:
Country:
Contact details
Are the contact details the same as (or similar to) the contact details given in section 1?:	YesNo
Email:
Telephone Number:	+
Other telephone number:	+
Contact Details 2
Are the details the same as (or similar to) the contact details given in section 1?:	YesNo
Email:
Telephone number:	+
Other telephone number:	+
Remove this persons details:
Add another persons details:
Section 5 of 7
Person with the Responsibility for the Notifiable Devices
Does a different person have responsibility for the notifiable devices?:	YesNo
First name(s):
Surname:
Position/job title:
Is the address the same as (or similar to) the address given in section 1?:	Yes No
Building number or name:
Street:
City or Town:
County:
Postcode:
Country:
Contact details no 2
Are the contact details the same as (or similar to) the contact details given in section one?:	Yes No
Email:
Telephone number:	+
Other telephone number:	+
Contact details no 3
Are the contact details the same as (or similar to) the contact details given in section 1?:	YesNo
Email:
Telephone Number:	+
Other telephone number:	+
Remove this persons details:
Add another persons details:
Section 6 of 7
Additional Details
Additional information which is required or may be relevant to the application
Please check local guidance notes and conditons for any additional information which may be required:
Section 7 of 7
No Fee
I hereby apply to Lisburn City council pursuant to:	I would confirm that the details that I have given are correct
Full name:
Date:
Digital Signature: