Once appointed your certifier is responsible to assess your building application and plans for compliance with the Building Act 2004 and Building Code of Australia and issue the building approval. Once your builder is issued with a Commencement Notice from your certifier the building work can commence and your certifier is responsible to inspect and certify that the building work carried out by your builder complies with the Building Act 2004 and Building Code of Australia

Lessee/Owner Details Please Print

Surname	
		First Name		
		
Company Name	

Position held in company			Australian Company/Business Number (ACN/ABN)		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS

Site Details Please Print

Block
			Section			Suburb			Unit
If applicable		

Street Address	

I hereby advise as required by the Building Act 2004 I have appointed:

Name of certifier	
	
as certifier in relation to the building work described in this form	

Lessee/s Signature/s	
	
Date: ______/______/______	

PRIVACY NOTE: The personal information on this form is being collected to enable a suitable auditing & compliance role of builders & certifiers by the Government appointed auditor & to provide statistical information to the Australian Bureau of Statistics on Building matters.	

Office Use Only - Fees Paid	
					
Building Levy $...............		Training Levy $...............		Workcover Fee $...............

	
Description of Building Work If more than 6 items please attach further details
Describe each item of building work in this building approval	BCA Occupancy Class	BCA Construction Type	Area (m2)	Number of Storeys	Cost of Works (refer to building cost guide)	
1
						
2
						
3
						
4
						
5
						
6

Applicable approved requirements and reasons why building approval is not prevented from being issued

Is all work exempt from development approval?

•	YES	Attach assessment for exempt development checklist (if applicable)	
		
•	NO	Provide reason/s or description of work:  _____________________________________________________________
 	
Description of Attachments compliant with Division 3.3 Building Act 2004 
(Please attach any additional documentation not listed below)

•	Building Approval Plans		•	Referrals, consultations & consents outcomes		•	Asbestos Advice -  If documents accompanying building approval do not include an asbestos assessment report as per the  Building Act 2004, the building approval must have an AA attached as per the Act
	
Utilities

This application must also be accompanied by a Statement of Compliance from each relevant utility provider (for water, sewerage, electricity and stormwater) which confirms that the location and nature of earthworks, utility connections, proposed buildings, pavements and landscape features comply with utility standards, access provisions and asset clearance zones.

Note 1: If there is no stormwater easement or Territory owned stormwater pipes located within the property boundary, a "Statement of Compliance" for stormwater from TAMS (Asset Acceptance) is not required to be obtained

Note 2: Where there is conflict between planning and utility requirements, the utility requirements take precedence over other codified or merit provisions

Utilities – Demolition Only

This application must be accompanied by a Statement of Endorsement for utilities (including water, sewerage, electricity and stormwater) stating that:
•	all network infrastructure on or immediately adjacent the site has been identified on the plan
•	all potentially hazardous substances and conditions (associated with or resulting from the demolition process) that may constitute a risk to utility services have been identified
•	all required network disconnections have been identified and the disconnection works comply with utility requirements
•	all works associated with the demolition comply with and are in accordance with utility asset access and protection requirements
Note: The documentation provided to the utility provider for endorsement must be consistent with the documentation that forms part of a development approval or the documentation verified as exempt from requiring development approval by a licensed certifier.

Insurance

For residential building work provide details of insurance where applicable (please attach a copy of the relevant insurance or fidelity certificate).

Insurance 
Provider	
	Policy No.		Date Issued	……./……./…….	

Entitlement to act as a Certifier

In performing services as a certifier in relation to this work I am not in breach of my entitlement to act as a certifier in accordance with the Building Act 2004.

Name:		COLA Lic No.		Date Issued	….…/….…/….…	

Signature:			
Date:	
……./……./…….