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.

APPLICATION FOR CERTIFICATE OF OCCUPANCY AND USE
Building Act 2004, S151

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.	

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

                    Company Details

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):

•	Email   	____

•	send certificate by post to the owner(s) address                  q held for collection from Building Services Shopfront - Mitchell

•	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 give it to your certifier to lodge or hand deliver to:

Access Canberra
Building Services Shopfront,
8 Darling Street Mitchell ACT 2911

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

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.	

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