D14/8892 Building Template – Application – Certificate of Acceptance – BC 10
Send or deliver your application to: Stratford District Council, PO Box 320,
Miranda Street, Stratford 4352. For enquiries, phone (06) 765 6099
Please provide two copies of all attachments, unless otherwise stated.
PART 1
The building (PROJECT LOCATION)
Building name (if applicable)
Building street address
Location of building within the site (include nearest street access)
Legal description of land where the building is located. (Lot/Section, DP, Block, Survey District etc):
Number of levels (include below ground, ground and above ground)
Level/unit number (if applicable)
Area (in square metres)
Existing floor area: Proposed new floor area: Resulting total floor area:
Current, lawfully established use of all parts of the building (include number of occupants per level and per use if more than
one level)
Year first constructed (insert year, an approximate date is acceptable such as 1920’s or 1960-1970)
The owner (MUST BE COMPLETED FOR ALL APPLICATIONS AND ALL DETAILS MUST BE THE
OWNER’S)
Owner’s name. If the owner is a company or other organisation provide the company or organisation name and a contact
person’s name
Owner’s mailing address
Street address/registered office
Owner’s contact details
Landline Mobile After hours
Email
Proof of ownership – attach one of the following as evidence
Copy of the land title (Computer register, Certificate of Title, CT or property title) – no more than three months old.
Lease Agreement for sale and purchase
APPLICATION FOR CERTIFICATE OF ACCEPTANCE
SECTION 97 BUILDING ACT 2004
Office Use Only:
Application #
Property ID
D14/8892 Building Template – Application – Certificate of Acceptance – BC 10
AGENT (only required if application is being made on behalf of the owner)
Name of agent. If application is for a company, trust or other organisation provide a contact person’s name
Agent’s mailing address
Street address/registered office
Agent’s contact details
Landline: Mobile: After hours:
Email:
Relationship to owner (state the details of the owner’s authorisation if making this application on the owner’s behalf)
Contacts (PROVIDE ALL DETAILS WHERE RELEVANT)
Designer or Architect Business/name
Address
Registration/qualification Mobile Landline
Email
Builder Business/name
Address
Registration/qualification Mobile Landline
Email
Other (Attach additional page if required)
Role Business/name
Address
Email
Registration/qualification Landline
Mobile
Application
I request that you issue a Certificate of Acceptance for the building work described in this application.
Signed by the owner OR
Signed by the agent (on behalf of, or with the
authority from, the owner)
Signature Signature
Name Name
Date Date
D14/8892 Building Template – Application – Certificate of Acceptance – BC 10
Privacy information
The information you have provided on this form is required so that your certificate of acceptance application can be
processed under the Building Act 2004. The Council collates statistics relating to issued building consents and has a
statutory obligation to forward these regularly to Statistics New Zealand. The Council stores the information on a public
register, which must be supplied (as previously determined by the Ombudsman) to whoever requests the information.
Under the Privacy Act 1993 you have the right to see and correct personal information the Council holds about you.
PART 2 – PROJECT
General information
Description of the building work (provide sufficient description to enable full understanding of the scope of the work).
Date building work was carried out.
Has a pre-application meeting been attended? Yes No Number
Will the building work result in a change of use of any part of the building? (If yes, provide details of the new use)
Yes No
Intended life of the building stated in years, only if intended to be less than 50 years old:
List building consents previously issued for the project (if any). List who issued the consent, the date of issue and the
consent number.
Estimated value of the building work on which the building levy will be calculated (including goods and services tax)
[state estimated value as defined in section 7 of the Building Act 2004].
$
Reasons why a Certificate of Acceptance is required
The owner (or the owner’s predecessor in Title) carried out building work for which a Building Consent was
required, but a Building Consent was not obtained because:
A Building Consent could not practicably be obtained in advance because the building work had to be carried out
urgently (delete one of the following):
(a) For the purpose of saving or protecting life or health or preventing serious damage to property as follows
(explain in detail):
D14/8892 Building Template – Application – Certificate of Acceptance – BC 10
(b) In order to ensure that a specified system was maintained in a safe condition or made safe as follows
(explain in detail):
OR
The Building Consent Authority that granted the Building Consent is unable or refuses to issue a Code Compliance
Certificate in relation to the building work, and no other Building Consent Authority will agree to issue a Code
Compliance Certificate for the building work.
Compliance Schedule (For Commercial Use Only)
There are no specified systems in the building.
The specified systems for the building are as follows: (Tick appropriate box(s))
Existing
Altered/
Added/
Remove
Specified
System
Existing
Altered/
Added/
Remove
Specified
System
Existing
Altered/
Added/
Remove
Specified
System
SS1
Automatic systems for fire
suppression.
SS2
Emergency warning
systems.
SS3/1 Automatic door.
SS3/2 Access controlled doors.
SS3/3
Interfaced fire or smoke
doors/windows.
SS4
Emergency lighting
systems.
SS5
Escape route pressurisation
systems.
SS6
Riser mains for use by fire
services.
SS7
A
utomatic back-flow
preventers connected to
potable water supply.
SS8/1 Passenger carrying lifts.
SS8/2 Services lifts.
SS8/3
Escalator and moving
walks.
SS9
Mechanical ventilation or air
conditioning systems.
SS10 Building maintenance units.
SS11
Laboratory fume
cupboards.
SS12/1 Audio loops.
SS12/2
FM radio and infrared beam
transmission systems.
SS13/1 Mechanical smoke control.
SS13/2 Natural smoke control.
13/3 Smoke curtains.
SS14/1
Emergency power
systems.
SS14/2 Signs for SS1-13.
SS15/1
Spoken information to
facilitate evacuation.
SS15/2 Final exits.
SS15/3 Fire separations.
SS15/4
Signs for facilitating
evacuation.
SS15/5 Smoke separations.
SS16 Cable cars.
Attachments
The following are attached to this application (Tick relevant box or write N/A) Office Use
Date of Construction: Provide proof of date of construction, such as signed/dated building contract payments.
Work closed in – Provide supporting evidence that work closed in and not able to be inspected complies with
the current building code:
Photographs
Relevant certification (Personnel who carried out the building work)
Architectural drawings (Plans and Specifications)
PS4 from supervising engineers (if applicable)
Expert opinion reports
Gas/Energy Compliance Certificates
Application Deposit: Fees are set out in Council’s Fees and Charges
Statement of Urgency:
Letter providing reason why works have been done under urgency. See sections 41(1)(c) and 42 “Owner must
apply for a certificate of acceptance if building work carried out urgently” of the Building Act 2004 (if applicable).
The Building Act is available Act is available online at legislation.govt.nz.
Officer Signature: Date:
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