Doc # 343306 Page 2 of 2 BA Form 15
Relationship to owner: (state the details
of the authorisation from the owner to
make the application on the owners behalf)
E. THE APPLICATION – I confirm that no code compliance certificate has been issued for the building work
It is intended to permit members of the public to use the premises / part of the premises described above for the following purposes and
in the following circumstances (describe purpose and circumstances):
Members of the public can use the premises / part of the premises described above safely because (state reasons for statement, and
include any precautions taken to protect the public, information on any specified systems in the premise / part of the premise, and the
management of any special risks (e.g. means of escape from fire) on site (provide information in attachments if necessary)):
The personnel who carried out the building works are as follows:
Trade Name Address Phone
Building contractor
Plumber
Fire safety coordinator
Other
I request that you issue, under Section 363A(2) of the Building Act 2004, a certificate for public use for the premises / part of the premises
described above:
Signed by the owner: OR Signature:
Name:
Date:
Signed by the agent:
(on behalf of, or
with authority from the owner)
Signature:
Name:
Date:
F. ATTACHMENTS
The following documents are attached to this application:
Evidence of applicants status
Plans and diagrams showing the premises / part of the premises described above
Documentation relevant to the safety of the premises / part of the premises (e.g. an engineers’ report, certificates concerning
specified systems
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