Fillable Building Certificate For Public Use Application (Whangarei District Council New Zealand)

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Building Certificate For Public Use Application (Whangarei District Council New Zealand)

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Private Bag 9023 | Whangarei 0148 | New Zealand
T: 09 430 4200 | 0800 WDC INFO | 0800 932 463 | F: 09 438 7632
W: www.wdc.govt.nz | E: mailroom@wdc.govt.nz
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
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Building Certificate For Public Use Application (Whangarei District Council New Zealand)

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Completed 18 July 2020

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