Doc # 343306 Page 1 of 2 BA Form 15
Application for certificate for public use
Version: 4
Date: January 2020
Code: BA Form 15
S
end or deliver your application to: Web: www.timaru.govt.nz
Building Services, Timaru District Council, Telephone: (03) 687 7236
2 King George Place, PO Box 522, Timaru 7940 Email: building@timdc.govt.nz
A. THE PREMISE / PART OF PREMISES (description of premises / part of premises for which certificate is sought)
Street or road address of building:
Building name:
(if applicable)
B. BUILDING WORK AFFECTING PREMISES / PART OF PREMISES
Building consent number(s):
Issued by: Timaru District Council
C. THE APPLICANT (person who owns, occupies, or controls premises)
Name of applicant: (include title)
Contact person: (if different from owner)
Mailing address:
Contact details:
Please attach one of the following as
evidence of ownership (tick if
included):
Landline number:
Daytime number:
Facsimile number:
Email address:
Copy of certificate and title
Agreement for sale and purchase
Property management agreement
Mobile number:
After hours number:
Lease
Licence
Other (state):
D. AGENT (only required if application is being made on behalf of the owner)
Name of agent:
Contact person:
Mailing address:
Contact details:
Landline number:
Daytime number:
Facsimile number:
Email address:
Mobile number:
After hours number:
Application no:
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 APPLICATIONI 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 engineersreport, certificates concerning
specified systems
click to sign
signature
click to edit
click to sign
signature
click to edit
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