Lease/Site Details 

Block	
	Section 		Suburb		Division		

Unit No		Street Address	

Building Approval Application and Site Work Details
This notice is issued in relation to the site work shown in the plans submitted as part of the application for a building approval dated made by the following applicants: 

_____________________________________________________________________________________________

_____________________________________________________________________________________________

on:  date________________________________ 

This notice applies to all site work in that application for which there is there is no— 
(a)	exemption assessment D notice stating that the site work is exempt development issued for the work not more than 3 months before the day the application was made;
(b)	 exemption declaration under the Planning and Development Regulation 2008, schedule 1, section 1.100A (1) (b) or section 1.100AB (1) (b) made by the planning and land authority; or
(c)	current development approval issued in relation to the site work. 

NOTE: Site work is development that is— 
(a)	building work; and
(b)	work other than building work that— 
(i) physically affects the place (the building site) where the building work is being carried out; and 
(ii) if not carried out at the building site, is carried out near, and connected with, the building site.
  
Examples: putting up temporary fencing, installing measures for erosion control, building a house, damaging or removing a significant tree, laying paving for driveways and parking areas, installing landscaping, site clearing and excavation, erecting site signage, erecting a pergola 

Building Certifier Details Please Print

Surname	
		First Name		
		
Company Name	

Licence  Number	
		Contact Number		

Postal Address	

Suburb	
		State			Postcode		

Building Certifier Statement

I state that: 
•	the plans for the building work to which the application for building approval relates show all the information necessary to establish that the site work is exempt development under the Planning and Development Act 2007, section 133; and
•	the site work is exempt development; and
•	I have assessed that the site work is exempt development for the following reasons and in accordance with the following provisions of the Planning and Development Regulation 2008 and Territory Plan Codes:

Please include all relevant regulations and codes relied on for your assessment and an outline of your reasoning, such the assessment you undertook, advice from referral entities, compliance with lease and development conditions etc. You can attach additional information if needed and supporting documents including checklists or your own assessment documents. You do not need to attach a copy of the plans or building approval application.

	

In 	

	

	

	

Please attach additional information if required	

Building Certifier Signature 
(or nominee)	

	Date of Issue		

Giving false or misleading information is a serious offence

Privacy Notice
The personal information on this form is provided to the Environment and Planning Directorate (EPD). The collection of personal information is authorised by the Building Act 2004.  If all or some of the required personal information is not collected this notice is not considered complete. The personal information provided 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 EPD 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
Phone: (02) 6207 1923	TTY: (02) 6207 2622			16 Challis Street Dickson ACT 2602 
Business Hours: 8.30am to 4.30pm weekdays (excluding Public Holidays)

Email: epdcustomerservices@act.gov.au	Website: www.environment@act.gov.au