This form is to be completed by the Building Certifier once satisfied that the building work detailed in this application is complete

PART A					PROJECT DETAILS 

Block/s	
	Section 		Suburb		Unit No.		

Street Address	

FULL NAME OF ALL OWNERS – All owners must be listed or application will not be processed  - Please Print

Owner 1 	
	Owner 2		

Owner 3		
Owner 4		

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

Describe each item of building work relevant to this application	BCA Occupancy Class	BCA Construction Type	Builders Name	
1

2

3

4

5

Please indicate if the project involved:

Electrical Work	•	YES	•	NO	Plumbing Work	•	YES	•	NO	Gas Work	•	YES	•	NO	

This building work is subject to an alternative solution under the BCA	•	YES	•	NO	
PART B					CERTIFIERS DETAILS

Name of Certifier	

Company Name	

Phone Number Business Hours			Mobile		
		
EMAIL ADDRESS

PART C					DECLARATION BY CERTIFIER

I am satisfied that the building work detailed in this application is complete. I hereby certify that:

▪	I have provided all the relevant documents required by subsection 48 of the Building Act 2004 with this application;
▪	the documentation relating to the building approval has been marked in accordance with the requirements of the Building Act 2004;
▪	this work has been undertaken in accordance with the building and development provisions within the Crown lease;
▪	the building work has been completed in accordance with the requirements of the Building Act 2004 and substantially in accordance with the approved plans;
▪	the building or part of the building as erected or altered is structurally sufficient, sound and stable for the purposes for which it is intended to be occupied or used; and
▪	the Registrar can issue a Certificate of Occupancy and Use.

If the owner of the land applies for a certificate the Registrar would be justified in issuing a certificate in respect of the work under the subsection below:

•	69(1)	•	69(2)	•	69(3)	•	71	•	72	of the Building Act 2004	

Certifier Name	
	Licence No.		
				
Certifier 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 complete this form must be lodged with the Mitchell Customer Service Centre and a copy must be forwarded to the owners.  The owners will not be able to apply for a certificate of occupancy or use if this form is not completed.

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