WARNING TO OWNERS
It is recommended that owners seek appropriate advice to determine whether the building work and other contract requirements have been completed satisfactorily before signing this form.  This form should not be signed before the completion of building work.

PART A						PROJECT DETAILS 

Block/s	
	Section 		Suburb		Unit No.		

Street Address	

Describe each item of building work to which this application relates: If more than 6 items please attach further details

1.	

2.	

3.	

4.	

5.

6.

Name of Certifier:	

PART B					OWNER/LESSEE DETAILS

FULL NAME OF ALL OWNERS – All owners must be listed or application will not be processed
Please Print - Owner 1 will be considered the contact person in relation to this application

Owner 1 		Owner 2		

Owner 3		
Owner 4		
						
Postal Address	

Suburb	
		State			Postcode		
					
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS

PART C					DECLARATION BY OWNER/S 

I am/we are: the owner(s) of the above described land

I am/we are satisfied that the building work and related requirements have been completed and hereby apply for a Certificate of Occupancy or Use in respect of the above described work to be issued and (select one option only):

•	send certificate by post to the owner(s) address	•	held for collection from the Mitchell Customer Service Centre
	
•	Other _______________________________________________________________________________	

PART D					SIGNATURE/S OF OWNER/S 

This form should not be signed before the completion of building work.

1stOwners Signature	
	Date		
				
2ndtOwners Signature	
	Date		
				
3rd Owners Signature	
	Date		
				
4th Owners Signature	

	Date		

NOTE: There are penalties for deliberately giving false and misleading information. The Planning and Land Authority or Minister may revoke an approval if satisfied that the approval was obtained by fraud or misrepresentation.

Once this form has been completed you should either give it it to your certifier to lodge or post/hand deliver to:
 
Mitchell Customer Service Centre, 
8 Darling Street
Mitchell ACT 2911

Privacy Notice
The personal information on this form is being collected to enable processing of your application and to enable auditing and compliance of builders and certifiers by the Government appointed auditor.  The information that you provide may be disclosed to the Australian Bureau of Statistics, ACT Revenue Office and the Taxation Office. The information may also be accessed by other government agencies and commercial organisations interested in building information.

Contact Details:
Environment and Sustainable Development Directorate
GPO Box 1908, Canberra City 2601
Customer Service Centre
8 Darling Street, Mitchell ACT 2911 and 16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923		TTY: (02) 6207 2622
Email: actpla.customer.services@act.gov.au		Website: www.actpla.act.gov.au