In completing this form the owner is authorising the builder nominated below to apply to the appointed certifier to issue a Commencement Notice for the works detailed in this application form.

PART A 					PROJECT DETAILS 

Block	
	Section 		Suburb		Unit No.		

Street Address	

Certifiers Name	

Description of Building Works relevant to this application-If more than 6 items please attach further details

1

2

3.

4

5

6

PART B					OWNERS DETAILS – Please Print

All owners must be listed 			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					APPOINTMENT OF BUILDER

I/we the owner/s have appointed the person whose details appear below as the builder in relation to the building works described in this form 

Licence Holders Name as it appears on licence card	

Licence Number	
		Class			Expiry Date		

List any conditions or endorsements on licence	

PART D					NOMINEE’S DETAILS
If the builder is a company or partnership provide details of the Nominee who will supervise the building work

Nominee’s Name	

Licence Number	
		Class			Expiry Date		

PART E					OWNERS SIGNATURE/S 

Ist Owners Signature	
	Date		
				
2nd Owners Signature	

	Date		
				
3rd Owners Signature

	Date		
				
4th Owners Signature

	Date		

PART F			BUILDER APPLICATION TO CERTIFIER FOR COMMENCEMENT NOTICE

I hereby apply to the building certifier listed above for a commencement notice for the works detailed in Part A of this form in accordance with the Building Act 2004.

Signature of Builder/Nominee	
	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.

PART G					INSURANCE OR FIDELITY CERTIFICATE

For residential building work please provide details of insurance where applicable

Insurance Provider	
		Policy No.			Date Issued		

PLEASE NOTE: 

•	A copy of this notice and where applicable the residential building insurance policy or fidelity certificate must be given to the Construction Occupations Registrar within one (1) week of the issue date.  

•	A copy of the Commencement Notice must also be provided to the owner/s.

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.