This form is to be used where building work has not been completed in accordance or substantially in accordance with the prescribed requirements for building work under the Building ACT 2004

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

Please indicate if the project involved:

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

This building work is subject to an alternative solution under the BCA	•	YES	•	NO	
			
PART B					OWNER/LESSEE DETAILS - Please Print

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

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 the Construction Occupations Registrar to issue a Certificate of Occupancy or Use in respect of the above described work and (select one option only):

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

Signature/s of Owner/s – all owners must sign this form

Owner 1 		Signature		DATE :	

Owner 2		
Signature	
	
DATE:	

Owner 3		
Signature		
DATE:	

Owner 4		
Signature		
DATE:	

PART D					CERTIFIER DECLARATION

The building work referred to herein appears to have been completed and I hereby give the Construction Occupations Registrar advice that:

I am not satisfied that the building work has been completed in accordance, or substantially in accordance with the prescribed requirements for building work under the Building Act 2004.

The following documents are provided where applicable:

•	a copy of the survey report.
•	details of work that could not reasonably be made to comply with the current Building Code but complied with the Building Code applicable when the plans were approved by government.

In my view, section 69(2B) of the Building Act 2004 applies to the building work and the Construction Occupations Registrar would be justified in issuing a Certificate of Occupancy and Use in respect of the work under this section.

Certifier Name	
	Licence    No. 		
				
Certifier Signature		Date	

PART E			CERTIFICATE OF OCCUPANCY AND USE DETAILS 

Certificate Number	
	Date issued		

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.

CONTACT INFORMATION
  Email:
    ACTPLAedevlopmentBA@act.gov.au	Post:
Access Canberra
Building Services 
Shopfront Mitchell
GPO Box 158
Canberra, ACT 2601	In Person:
Please visit www.act.gov.au/accessCBR
Or call 132281 to find an 
Access Canberra Shopfront.	

Privacy Notice                                                                                                                                                                                                                                                                
The personal information on this form is provided to Access Canberra 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 Access Canberra 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. Access Canberra’s Information Privacy Policy contains information about how you may access or seek to correct your personal information held by Access Canberra, and how you may complain about an alleged breach of the Territory Privacy Principles. Access Canberra Information Privacy Policy can be found at www.act.gov.au/accessCBR