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 provided to the Environment and Planning Directorate (EPD) to enable the processing of your application. The collection of personal information is authorised by the Planning and Development Act 2007.  If all or some of the personal information is not collected EPD cannot process your application. The Planning and Development Act 2007 requires the details of applications, decisions and orders to be kept on a register and made available for public inspection. Information and documentation relevant to a development application may be made available via the Internet. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office, the Registrar General’s Office, ACTEW Corporation, ActewAGL, Territory and Municipal Services Directorate and other Government agencies with a direct interest in the development assessment process.  The information may also be disclosed where authorised by law or court order, or where the Directorate reasonably believes that the use or disclosure of the information is reasonably necessary for enforcement-related activities conducted by, or on behalf of, an enforcement body. EPD’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by EPD, and how you may complain about an alleged breach of the Territory Privacy Principles. The EPD Information Privacy Policy can be found at www.environment@act.gov.au 

Contact Details:
Environment and Planning Directorate
Customer Service Centres
GPO Box 158, Canberra City 2601
8 Darling Street Mitchell, ACT 2911
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: epdcustomerservices@act.gov.au	Website: www.environment@act.gov.au