This form should be completed when applying for a
certificate certifying that the elimination or reinstatement
of a building or part of a building or a unit or part of a unit
in a units plan is exempt from the requirements to obtain
development approval under Part 7 of the Planning and 
Development Act 2007

Lease/Site Details Please Print

If more than one lease/site, attach the following details for each lease/site

Block	

Section

Suburb

Units Plan Number

	
		
Street Address	

Postcode	

Applicant Details Please Print

Surname	
		First Name		
		
Company Name	

              Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
Email Address

Unit Owner/Owners Corporation Details Please Print

1st Unit Owner/Executive Member’s Details

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	

2nd Unit Owner/Executive Member’s Details

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	

Description of Building Work Please Print

Please tick appropriate box

-	Elimination of a building or part of building or a unit or part of a unit

-	Reinstatement of a building or part of building or a unit or part of a unit

Description

Approved Plans

Are there copies of plans for the elimination or reinstatement of the building(s)/unit(s) for the land specified in this application attached?

	•	NO
•	YES	
Conflict of Interest Declaration

Does the applicant or lessee have any association with Planning and Land Authority staff?	•	NO
•	YES	
If YES - please provide details:	

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.

Applicant and Owners Corporation Declaration

I/we the undersigned, hereby apply for a provisional building damage order certificate on the land specified in this application;

I/we declare that this application is accompanied by all of the required information or documents for it to be considered for approval;

I/we understand that the documentation provided will be considered to be the relevant documentation associated with this application;

I/we the undersigned appoint the applicant whose signature appears below to act on my/our behalf in relation to this application for a provisional building damage order certificate. This authorises the applicant to pay all application fees, bonds and securities, liaise with the Planning and Land Authority when required, alter, amend or provide further information as necessary and receive any communications relating to this application for a provisional building damage order certificate;

I/we declare that all the information given on this form and its attachments is true and complete;

If signing on behalf of a company or organization:

I/we the undersigned, declare I/we have the appropriate delegation or authority to sign on behalf of the company or organisation.

Applicant Signature (s)	
	Date		

1st Unit Owner/Executive Member’s Signature	
	Date		

2nd Unit Owner/Executive Member’s  Signature	
	Date		

Contact Details:
Environment and Sustainable Development Directorate
Customer Service Centre
GPO Box 1908, Canberra City 2601
16 Challis Street, Dickson ACT 2602
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Phone: (02) 6207 1923		Fax: (02) 6207 1925		TTY: (02) 6207 2622
Email: actpla.customer.services@act.gov.au	Website: www.actpla.act.gov.au

Privacy Notice
The personal information on this form is being collected to enable processing of your application.  Collection of personal information is authorised by the Unit Titles Act 2001.  The information that you provide may be disclosed to Government Agencies such as the ACT Revenue office and the Registrar-General’s Office.