This form is to be used where building work has not been completed in accordance or substantially in accordance with the prescribed requirements for building work under the Building ACT 2004

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

Please indicate if the project involved:

Electrical Work	•	YES	•	NO	Plumbing Work	•	YES	•	NO	

This building work is subject to an alternative solution under the BCA	•	YES	•	NO	
			
PART B					OWNER/LESSEE DETAILS - Please Print

FULL NAME OF ALL OWNERS – All owners must be listed or application will not be processed
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 the Construction Occupations Registrar to issue a Certificate of Occupancy or Use in respect of the above described work and (select one option only):

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

Signature/s of Owners – all owners must sign this form

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

	Date		

PART D					CERTIFIER DECLARATION

The building work referred to herein appears to have been completed and I hereby give the Construction Occupations Registrar advice that:

I am not satisfied that the building work has been completed in accordance, or substantially in accordance with the prescribed requirements for building work under the Building Act 2004.

The following documents are provided where applicable:

•	a copy of the survey report.
•	details of work that could not reasonably be made to comply with the current Building Code but complied with the Building Code applicable when the plans were approved by government.

In my view, section 69(2B) of the Building Act 2004 applies to the building work and the Construction Occupations Registrar would be justified in issuing a Certificate of Occupancy and Use in respect of the work under this section.

Certifiers Name	
	Licence No.		
				
Certifiers Signature		Date	

PART E			CERTIFICATE OF OCCUPANCY AND USE DETAILS 

Certificate Number	
	Date issued		

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.
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