1. Where is the building?
Complete all fields
Street address of building:
Building consent number:
2. Who owns the building?
Complete all fields, using N/A where not applicable
Owner name: Title: e.g. Mr, Mrs, Ms, Dr
Owner email address:
Owner contact numbers: Ph: Cell:
Owner mailing address:
3. What work have you carried out / supervised?
Complete all fields for each line, using N/A if a line is
not applicable
I carried out/supervised the following design work that is restricted building work:
Work that is
restricted building
work
Tick all that apply
Description of restricted building
work
Carried out / supervised
Complete these fields if the previous column is ticked Yes
Primary structure
Yes N/A
Foundations / subfloor
framing
Yes N/A
Walls
Yes N/A
Roof
Yes N/A
Columns / beams
Yes N/A
Bracing
Yes N/A
Other
Yes N/A
External moisture
management systems
Yes N/A
Damp proofing
Yes N/A
Roof cladding or roof
cladding system
Yes N/A
Ventilation system (for
example, subfloor or
cavity)
Yes N/A
MEMORANDUM FROM LICENSED BUILDING PRACTITIONER:
RECORD OF BUILDING WORK (Form 6A)
Section 88. Building Act 2004.
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GoShift LBP Record of Work
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Wall cladding or wall
cladding system
Yes N/A
Waterproofing
Yes N/A
Other
Yes N/A
4. What are your details?
Complete all fields or enter N/A where not applicable
Licensed Building
Practitioner name:
Licensed Building
Practitioner number:
Classes licensed in: Plumbers, Gasfitters
and Drainlayers Board
registration number (if
applicable):
Mailing address:
Street address or
registered office:
Contact number:
Email address:
5. Declaration
I, ____________________________________________[
name of Licensed Building Practitioner
], carried out or supervised the
restricted building work recorded on this form.
Signature:
Date:
Yo
u can add a digital signature to this document, either using Adobe or your existing digital signature.
Once you have filled out the form, including signatures, please save the application to your computer. You can then
submit the application with supporting documentation to your local council.
If you are unsure about what information to include in your application, a guidance document is available (click here).
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GoShift LBP Record of Work
Page 2 of 2
click to sign
signature
click to edit
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