WARNING TO OWNERS
It is recommended that owners seek appropriate advice to determine whether the building work and other contract requirements have been completed satisfactorily before signing this form.  This form should not be signed before the completion of building work.

PART A						PROJECT DETAILS 

Block/s	
	Section 		Suburb		Unit No.		

Street Address	

Describe each item of building work to which this application relates: If more than 6 items please attach further details

1.	

2.	

3.	

4.	

5.

6.

Name of Certifier:	

PART B					OWNER/LESSEE DETAILS

FULL NAME OF ALL OWNERS – All owners must be listed or application will not be processed
Please Print - 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					DECLARATION BY OWNER/S 

I am/we are: the owner(s) of the above described land

I am/we are satisfied that the building work and related requirements have been completed and hereby apply for a Certificate of Occupancy or Use in respect of the above described work to be issued and (select one option only):

•	send certificate by post to the owner(s) address	•	held for collection from the Mitchell Customer Service Centre
	
•	Other _______________________________________________________________________________	

PART D					SIGNATURE/S OF OWNER/S 

This form should not be signed before the completion of building work.

1stOwner’s Signature	
	Date		
				
2ndtOwner’s Signature	
	Date		
				
3rd Owner’s Signature	
	Date		
				
4th Owner’s Signature	

	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.

Once this form has been completed you should either give it to your certifier to lodge or hand deliver to:
 
Environment and Planning Directorate
Mitchell Customer Service Centre, 
8 Darling Street
Mitchell ACT 2911

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