In completing this form the owner is authorising the builder nominated below to apply to the appointed certifier to issue a Commencement Notice for the works detailed in this application form.

PART A 					PROJECT DETAILS 

Block	
	Section 		Suburb		Unit No.		

Street Address	

Certifier Name	

Description of Building Works relevant to this application-If more than 6 items please attach further details

1

2

3.

4

5

6

PART B					OWNER DETAILS – Please Print

All owners must be listed 			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					APPOINTMENT OF BUILDER

I/we the owner/s have appointed the person whose details appear below as the builder in relation to the building works described in this form 

Licence Holders Name as it appears on licence card	

Licence Number	
		Class			Expiry Date		

List any conditions or endorsements on licence	

PART D					NOMINEE’S DETAILS
If the builder is a company or partnership provide details of the Nominee who will supervise the building work

Nominee’s Name	

Licence Number	
		Class			Expiry Date		

PART E					OWNER SIGNATURE/S– all owners must sign this form

Owner 1 		
Signature		
DATE :	

Owner 2		
Signature	
	
DATE:	

Owner 3		
Signature		
DATE:	

Owner 4		
Signature		
DATE:	

PART F			BUILDER APPLICATION TO CERTIFIER FOR COMMENCEMENT NOTICE

I hereby apply to the building certifier listed above for a commencement notice for the works detailed in Part A of this form in accordance with the Building Act 2004.

  A site sign was not required to be displayed prior to making this application. 

  A site sign was required to be displayed prior to making this application and I declare that a compliant sign was 
       erected and displayed for the required period.

Signature of Builder/Nominee	
	Date		

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.

PART G					INSURANCE OR FIDELITY CERTIFICATE

For residential building work please provide details of insurance where applicable

Insurance Provider	
		Policy No.			Date Issued		

PLEASE NOTE: 

•	A copy of this notice and where applicable the residential building insurance policy or fidelity certificate must be given to the Construction Occupations Registrar within one (1) week of the issue date.  

•	A copy of the Commencement Notice must also be provided to the owner/s.

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 Building Act 2004.  If all or some of the personal information is not collected EPD cannot process your application. The personal information you provide may be disclosed to Australian Bureau of Statistics, ACT Revenue Office and the Taxation Office.  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