TO BE COMPLETED BY THE PERSON THAT WILL BE UNDERTAKING THE WATER, WASTEWATER AND/OR
STORMWATER NETWORK PHYSICAL CONNECTIONS.
Please complete and return this form to: networkauthorisation@qldc.govt.nz
Phone: (03) 441 0499
Website: www.qldc.govt.nz
1. YOUR DETAILS
First name: Middle name:
Contact address
Street number:
Street name:
Suburb / City: Postcode:
Work phone: Mobile:
Email:
Last name:
2. DECLARATION
Please tick the boxes relevant to the qualication(s) you have for water and/or wastewater (WW) & stormwater
(SW) connections.
Water WW & SW
I have attached evidence of my qualication:
New Zealand Certicate in Infrastructure Works (Pipeline Construction and Maintenance) (Level 4) (with
strands in Drinking-water, Wastewater and Stormwater, and Trenchless Technologies), and/or
I conrm I am a Registered and licensed Certifying level Drainlayer (Tier 1) with qualications, registration
and annual practising license as required by the Plumbers, Gastters and Drainlayers Board (PGDB) and
as listed on the public register of Certifying level Drainlayers on the PGDB website
I conrm I have:
• undertaken the required testing, inoculations and immunisations listed in App 4, and
• I, or my employer have provided evidence of current:
o public liability insurance for an amount not less than $10,000,000, and
o motor vehicle third party liability insurance for an amount not less than $10,000,000
Name: Signature:
3. FOR OFFICE USE ONLY – APPROVED BY:
Name: Signature:
Job title:QLDC Approved Contractor register reference number:
Job title: Date:
Job title:
Date and method Applicant advised of approval:
APPROVED CONTRACTOR
APPLICATION FORM
for water, wastewater, and stormwater
network physical connection works
