Under section 76 of the Building Act 2004  it is an offence for a person to use, or to permit another person to use, a regulated swimming pool (including a regulated spa pool) unless the requirements of the Building Act 2004 have been met, including the issue of a certificate of occupancy or use for the swimming pool where required. 

This form is to be used to certify that pool fencing or other pool barriers are compliant with the requirements of Building (General) Regulation 2008, Schedule 1 (Exempt buildings & building work), Part 1.3, item 13, column 4.

PART A				PROJECT DETAILS 

Block	
	Section 		Suburb		Unit No.		

Street Address	

Description of pool fencing or other relevant barrier component, tick all that apply:

 metal rod or tube pool fencing			 building enclosing the indoor pool
 timber paling fencing				 exterior walls of a building
 metal sheet fencing				 window of a building
 glass panel fencing				 door of a building
 masonry fence or freestanding wall		 other ________________________

PART B				BUILDING SURVEYOR DETAILS

In accordance with Building (General) Regulation 2008, Schedule 1 (Exempt buildings & building work), Part 1.3, item 13, column 4, paragraph (c)  I/we herby advise that I/we the lessee/s have engaged the building surveyor whose details appear below as the certifier to inspect and certify the work described above. 

Company Details (if applicable)	

Name of Building Surveyor	
		ABN/
ACN		

Postal Address	

Suburb	
		State			Postcode		
					
Phone Number Business Hours			Mobile		
		
PART C				AUTHORITY TO ACCESS BUILDING FILE 

By signing Part F of this form I/we the lessee/s of the abovementioned property hereby authorise the building surveyor to access the building file for the purposes of obtaining information relevant to this application.

PART D				DOCUMENTATION TO BE SUBMITTED WITH THIS FORM
The following documents MUST be submitted with this form:

A site plan showing:
•	the block or unit boundaries 
•	the location and description of the subject pool fencing or pool barrier

PART E				BUILDING SURVEYOR DECLARATION	

I hereby certify that:
I have inspected the fencing and/or barrier;
		The fencing and/or barriers comply with the building code;
		The fencing and/or barriers have been constructed in a proper and skilful way;
		The fencing and/or barriers are compliant with the Building Act 2004 (other than part 3).

Building Surveyor Name:
Please Print	

ACT Licence Number:	

Building Surveyor Signature:		
DATE: ____/____/____	

PART F				APPLICATION FOR CERTIFICATE OF OCCUPANCY AND USE 

I am/we are: the owner(s) of the above land described in Part A of this form. I am/we are satisfied that the building work and related requirements have been completed and hereby apply for a Certificate of Occupancy and Use in respect of the work described above to be issued.

FULL NAME OF ALL OWNERS Please Print 

Owner 1 		
Signature		

Owner 2		
Signature		

Owner 3		
Signature		

Owner 4		
Signature		

DATE: ______/______/______

Note: The Certificate of Occupancy and Use once issued will be emailed to the Lessee and Building Surveyor.

Lessee email address (please print)	_______________________________________________________________________

Building Surveyor email address (please print) _________________________________________________________________

FEES:	There is a fee payable to submit this application.  Once this form is complete it can be forwarded to EPD

Via email:
ACTPLAedevlopmentBA@act.gov.au		In person:
Mitchell Customer Service Centre, 8 Darling Street
8.30am – 4.30pm Monday to Friday (excluding public holidays)	
NOTE: If sending via email – a customer service officer will contact you by telephone for payment once form has been received

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 			Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)
Customer Service Centres 				Phone: (02) 6207 1923	TTY: (02) 6207 2622
GPO Box 158, Canberra City 2601
8 Darling Street Mitchell, ACT 2911
16 Challis Street Dickson ACT 2602
Email: epdcustomerservices@act.gov.au	Website: www.environment@act.gov.au