Lease/Site Details Please Print

Block	
	Section 		Suburb		Unit No.		

Street Address	

Owners Details – All owners MUST be listed 

Owner 1 		Owner 2		

Owner 3		
Owner 4		

Description of Works relevant to the Notice If more than 3 items please attach further details

1

2

3.

Works Assessor or Building Surveyor Details Please Print

Surname	
		First Name		
		
Company Name	

ACN Number	
		Licence Number		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

DATE OF ISSUE   - S138D(d) Planning and Development Act 2007

A copy of the Exemption Assessment D Notice must be provided to Planning and Land Authority within 
5 days after the day the works assessor or building surveyor issues the notice.

Date notice issued	

Documentation Checklist 

	Provided
•			Provided
•		
Exemption Assessment D Notice 		A copy of the plans and documents used in the exemption assessment of the building work provided		
The exemption must be marked on, or attached to, or partly marked on or partly attached to, each page of the plans used by the works assessor or building surveyor in the assessment 		Plans have been initialled , dated and marked with  the works assessor or building surveyor’s licence number on each page of the plans & numbered consecutively through each document, starting with the number 1 Each page states the total number of pages comprising the attached documents		

Note: If, because of the size of the plans, it is impractical to mark the exemption on each page of the plans, the works assessor/building surveyor may, instead of marking the exemption on each page of the plans, mark each page of the plans with his/her initials, licence number and date; and indicate that the details of the exemption are in the exemption assessment D notice.

Works Assessor/Building Assessor Declaration

I declare I have issued the attached Exemption Assessment D Notice in accordance with the requirements of the Planning and Development Act 2007 and Planning and Development Regulations 2008.

Works Assessor/Building Surveyor Signature	

	Date		

NOTE: There are penalties for deliberately giving false and misleading information.

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.