1. art and entertainment
2. visual art and design
3. design

Cassowary Coast Regional Council
A.B.N. 20 889 787 211
PO Box 887, INNISFAIL, QLD 4860 Phone: 1300 763 903, Fax: 07 4061 4258
[email protected]
APPLICATION
MONUMENTAL WORKS / PLAQUE INSTALLATION
SECTION 1
APPLICANT DETAILS:
Name of Applicant
Postal Address
Contact Phone No
Relationship to interred
CEMETERY:
Innisfail
Cardwell
Tully
Murrigal
New Tully Lawn
Jumbun
INTERRED DETAILS:
Surname
First Name
Middle Names
Date of Death
Section No
Row No
Plot No
Funeral Director
DECLARATION: I, the applicant as detailed above, hereby submit application for: (please tick appropriate box)
Monumental Works Permit
I have completed Sections 1 & 2
Lawn Cemetery Plaque Installation
I have completed Section 1
Niche Plaque Installation
I have completed Section 1
I verify that all information provided in this application to be true and correct.
Signed:______________________________
Date: _______________________
Monumental Works - Cleaning Deposit Conditions: If work is not completed 3 months after date of application the cleaning deposit will be
refunded and a new application will be required.
Privacy Policy: The Cassowary Coast Regional Council respects your privacy. Personal information on this form is collected in accordance
with the Information Privacy Act 2009 guidelines and is used only by Council staff for the purpose of financial functions and will not be
disclosed unless required by law.
Plaque Installation Completed:
Date_________________ Cemetery Sexton ______________________________________
FEES
Plaque Placement Fee:
Plaque: Lawn Cemetery and Niche Placement (per plaque)
Monumental Works:
Works Permit (per permit private or contractor per grave/plot)
Cleaning Deposit Bond - Private (per grave/per plot)
Cleaning Deposit Bond - Contractor (per year per contractor)
Office Use Only:
Tick Applicable
Receipt No: _______________ Date: ____________________
GST
TOTAL (Inc GST)
6.81
75.00
6.81
13.63
45.45
75.00
150.00
500.00
Cashier’s Name: _________________________
C:\Users\Vanessa.Kerr\Appdata\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\6EH16DL0\Monumental Works - Plaque Install Application 20142015.Doc
Cleaning Deposit Bond - Date Refunded ______________________ Refund approved by: _________________________
SECTION 2:
HEADSTONE SPECIFICATION:
(Excludes Sections 25 and 27)
WHOLE OF SITE COVERAGE (3.048m x 1.829m)
MONUMENTAL LAWN HEADSTONE BEAM:
•
Maximum Height:
600MM
•
Maximum Base Width :
200MM
•
Maximum Base Length 800MM
•
Leading edge of monumental headstone recessed 150mm from concrete beam edge.
600MM
200MM
Sketch Plan or Description of proposed concrete slab/headstone to be shown below or
MUST BE ATTACHED
C:\Users\Vanessa.Kerr\Appdata\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\6EH16DL0\Monumental Works - Plaque Install Application 20142015.Doc
PLAQUE SPECIFICATIONS:
Innisfail Cemetery
Lawn Plaque:
Columbarium wall plaque:
380mm long x 216mm wide
178mm long x 142mm wide
Tully Cemetery
Large lawn plaque:
Small lawn plaque:
Columbarium wall plaque:
520mm long x 305mm wide
315mm long x 210mm wide
230mm long x 175mm wide
Cardwell Cemetery
Lawn plaque:
380mm long x 280mm wide
Cassowary Coast Regional Council – Information Privacy Statement: The Cassowary Coast Regional Council respects your privacy. Your personal
information has been collected for the purpose of processing a permit to carry out monumental work or a plaque installation at one of the Cassowary
Coast Regional Council cemeteries. The collection of your information is authorised under the Cassowary Coast Regional Council Subordinate Local
Law No 1 (Administration) 2011. Schedule 15 - Operation of cemeteries. Your personal information will not be disclosed to any other person or agency
unless you have given your permission or Council is required to do so by law. You may apply to access this information on the appropriate form
obtainable from Council Website at any time.
C:\Users\Vanessa.Kerr\Appdata\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\6EH16DL0\Monumental Works - Plaque Install Application 20142015.Doc
C:\Users\Vanessa.Kerr\Appdata\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\6EH16DL0\Monumental Works - Plaque Install Application 20142015.Doc