Section 296 of the Planning and Development Act 2007 states that a lessee may apply to the Planning and Land Authority for a certificate of compliance. In applying for the certificate, please ensure that all provisions of your Crown lease have been complied with. A copy of the certificate of occupancy and use must be provided at the time of lodgement of this application.

Lease Details Please Print

Block	

Section	
	Unit (if applicable)		
		
Suburb	

District	

Street Address	

Applicant Details Please Print

Surname	
		First Name		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

Lessee (Property Owners) Details Please Print

1st Lessee’s Details 

Surname	
		First Name		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

2nd Lessee’s Details 

Surname	
		First Name		
		
Postal Address	

Suburb	
		State			Postcode		
				
Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS	

All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Applicant and Lessee Declaration

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

If signing on behalf of a company, organisation or Government agency:-

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

Applicant Signature (s)	
	Date		
				
1st Lessee’s Signature	
	Date		
				
2nd Lessee’s Signature	
	Date		
				
All lessees must sign authorising the lodgement of this application. In doing so the lessee gives authority to the applicant to negotiate any dealings in relation to the application through to its determination.  If there are more than two lessees please ensure that the details and authorisation are attached to the application.

Privacy Notice
The personal information on this form is being collected to enable processing of your application. Collection of personal information is authorised by Chapters 7, 8 and 9 of the Planning and Development Act 2007. The information that you provide may be disclosed to the ACT Revenue Office and the Registrar-General’s Office. The information may be accessed by other government agencies, ACTEWAGL, ACTEW Corporation and other commercial organisations interested in development and building information. 

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

Office Use Only

Date lodged  ----/----/----	•	C of O provided 	•	Lessee Details Checked (TARQUIN)	
				
Receiving officer: