Private Bag 9023 | Whangarei 0148 | New Zealand
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06/334867 October 2010
Application for Certificate for Public Use Form 15
Section 363A, Building Act 2004
Premises/part of premises
Description of premises/part of premises for which certificate is sought:
Building work affecting premises/part of premises
Building consent(s) no(s)
Issued by Whangarei District Council
The applicant (person who owns, occupies or controls premises)
Name of applicant
(if an individual - include preferred form of address, e.g. Mr, Ms, Mrs, Dr)
Contact person
1
Mailing address
After hours phone
The following evidence of the applicant’s status as owner/occupier/person in control is attached to this application
one or more
Copy of certificate of title
Lease
Agreement for sale and purchase
License
Property management agreement
Other (state) being a document that shows the full name of applicant
The owner’s name & address
2
Agent
3
Name of agent
(only required if application is being made on behalf of the owner/occupier/person in control of premises)
Contact person
4
Mailing address
Day phone
After hours phone
Fax number
Relationship to owner/occupier/person in control of premises
(state details of authorisation from owner/occupier/person in control of the premises to make the application on the person’s behalf)
1
Delete if owner/occupier/person in control is an individual
2
Delete if applicant is the owner
3
Delete this section if the application is not being made on behalf of the owner/occupier/person in control
4
Delete if the agent is an individual
06/334867 October 2010 2
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:
Members of the public can use the premises/part of the premises described safely because:
(state reasons for statement, & include any precautions taken to protect the public, information on any specified items in the
premises or part of the premises, & the management of any special risks e.g. means of escape from fire on site provide
information in attachments if necessary)
The personnel who carry out the building work are as follows:
(if known, list names, addresses, phone numbers and where relevant registration numbers)
I request that you issue, under section 363A(2) of the Building Act 2004, a certificate for public use for the premises or
the part of the premises described above.
Signature
(owner/occupier/person in control of premises/agent on
behalf of, & with the authority of the owner, occupier person)
Printed name of person signing
Date
Attachments
1 Evidence of applicant’s status
2 Plans and diagrams showing the premises of part of the premises described above
3 Documentation relevant to the safety of the premises/part of the premises (e.g. engineer’s report, certificates
concerning specified systems)
Return form to:
Whangarei District Council
Private Bag 9023
WHANGAREI 0148
Office use
Print form
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