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A. Project Information B. Contact Information

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Application
Schedule 1: Designer Information
A. Project Information
Street No.
Street Name
Unit/Suite No.
Lot/con.
City/Town
Postal Code
B. Contact Information
Individual who reviews and takes responsibility for design activities
First Name
Last Name
Street No.
Street Name
Unit/Suite No.
Lot/con.
Telephone No.
Municipality
Province
Postal Code
Mobile No.
E-mail Address
Fax No.
C. Design Activities
Undertaken by individual identified in “Contact Information”. [Building Code Table 3.5.2.1. of division C]
House HVAC — House Building Structural
Small Buildings Building Services Plumbing — House
Large Buildings Detection, Lighting and Power Plumbing — All Buildings
Complex Buildings Fire Protection On-site Sewage Systems
Description of designer's work
Continue on next page.
14-0070 2015-07
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The personal information on this form is collected under the City of Toronto Act, S.O. 2006, Chapter 11, Schedule A, s. 136 (b) & (c)
and the Ontario Building Code Act, S.O. 1992, Chapter 23. The information collected will be used for processing applications and creating
aggregate statistical reports. Questions about this collection may be referred to the Customer Service Manager in the appropriate district.
Toronto East York District, 100 Queen Street West, Ground Floor, West Tower, Toronto M5H 2N2; North York District,
5100 Yonge Street, 1st Floor, Toronto M2N 5W4; Etobicoke York District, 2 Civic Centre Court, 1st Floor, Toronto
M9C 2Y2; Scarborough District, 150 Borough Drive, 3rd Floor, Toronto M1P 4N7.
Phone: (416) 397-5330
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D.
Designer Declaration
Application
Schedule 1: Designer Information
I
declare that (choose one as appropriate):
(print name)
I review and take responsibility for the design work on behalf of a firm registered under subsection
3.2.4. of Division C, of the Building Code. I am qualified, and the firm is registered, in the appropriate
classes/categories.
Individual BCIN:
Firm BCIN:
I review and take responsibility for the design and am qualified in the appropriate category as an
"other designer" under subsection 3.2.5.of Division C, of the Building Code.
Individual BCIN:
Basis for exemption from registration:
The design work is exempt from the registration and qualification requirements of the
Building Code. Basis for exemption from registration and qualification:
I certify that:
1. The information contained in this schedule is true to the best of my knowledge.
2. I have submitted this application with the knowledge and consent of the firm.
Signature
Print Name
Date (yyyy-mm-dd)
NOTE:
1. For the purposes of this form, "individual" means the "person" referred to in Clause 3.2.4.7(1)(c). of Division C,
Article 3.2.5.1. of Division C, and all other persons who are exempt from qualification under subsections 3.2.4.
and 3.2.5.
of Division C.
2. Schedule 1 is not required to be completed by a holder of licence, temporary licence, or certificate of
practice, issued by the Ontario Association of Architects. Schedule 1 is also not required to be completed by
a hol
der of a li
cence to practise, a limited licence to practise, or
a certificate of authorization, issued by
the Association of Professional Engineers of Ontario.
14-0070 2015-07
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A. Project Information B. Contact Information

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Completed 22 January 2021

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