Apply for a Provisional Statement Application for a provisional statement to be granted under the Licensing Act 2003 Fields marked with * are required Before completing this form please read the guidance notes Applicant declaration I/We apply for a provisional statement under section 29 of the Licensing Act 2003 for the premises described in Part 1 below (the premises) and I/we are making this application to you as the relevant licensing authority in accordance with section 12 of the Licensing Act 2003* Part 1 – Premises details Postal address of premises or, if none, ordnance survey map reference or description* Address line 2 Post town* Postcode* Telephone number at premises (if any) Non-domestic rateable value of premises* Premises under construction, fee payable is £315 None to £4,300, fee payable is £100 £4,301 and £33,000, fee payable is £190 £33,001 and £87,000, fee payable is £315 £87,001 and £125,000, fee payable is £450 £125,001 or more, fee payable is £635 Next Page Last updated: 13/02/2023 08:14:12
