© Stratford District Council 2005 D10/25036 Version 2 BUILDING TEMPLATE - APPLICATION - AMENDMENT - COMPLIANCE SCHEDULE - BC 12.DOC Application Page 1 of 3
THE
BUILDING
Street Address of Building
(
For structures that do not have a street address, state the nearest street intersection and the
distance and direction from that intersection)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Le
gal Description of Land Where Building is located
(State legal description as at the date of application and, if the land is proposed to be subdivided,
include details of relevant Lot numbers and subdivision consent)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Building Name ................................................................................................................................
....
Location of Building Within Site/Block Number ................................................................
.............
(Include nearest street access)
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Level/Unit Number ................................................................................................
..............................
Current Lawfully Established Use ................................................................................................
....
(Include number of occupants per level and per use if more than one)
________________________________________________________________________________
________________________________________________________________________________
_______________________________
_________________________________________________
________________________________________________________________________
________
APPLICATION FOR AMENDMENT TO
COMPLIANCE SCHEDULE
SECTION 106, BUILDING ACT 2004
(Form 11)
© Stratford District Council 2005 D10/25036 Version 2 BUILDING TEMPLATE - APPLICATION - AMENDMENT - COMPLIANCE SCHEDULE - BC 12.DOC Application Page 2 of 3
THE OWNER
Name of
Owner ................................................................................................................................
......
(Include preferred form of address, eg: Mr, Miss, Dr if an individual)
Contact Person
................................................................................................................................
.....
M
ailing Address ................................................................................................................................
....
................................................................................................................................................................
..
Street Address/Registered Office
................................................................................................
.......
................................................................................................................................................................
..
Phone Number:
Landline: ................................................. Mobile: ................................
..........
Daytime: .................................................. After-hours: ................................
..
Email Address: ................................................................................................
..
Website: ................................................................................................
...............
E
vidence of Ownership:
……………………………………………………………………………………
[Copy of certificate of title,
lease, agreement for sale and purchase, or other document showing full
name of legal owner(s) of the building]
THE AGENT
Name of Agent ................................................................................................................................
.....
(Only required if application is being made on behalf of the owner)
Relationship with Owner ……………………………………………………………………………..…….
(State details of the authorisation from the owner to make the application on the owner's behalf).
Fi
rst Point of Contact for Communications with the Council
(State full name, mailing address, phone number(s), facsimile number(s), and email address/es).
................................................................................................................................
................................
Mailing Address ................................................................................................................................
..
................................................................................................................................
................................
Street Address/Registered Office ................................................................................................
.....
................................................................................................................................
................................
Phone Number: Landline: ................................................. Mobile: ................................
..........
Daytime: .................................................. After-hours: ................................
..
Email Address: ................................................................................................
...
Website: ................................................................................................
...............
© Stratford District Council 2005 D10/25036 Version 2 BUILDING TEMPLATE - APPLICATION - AMENDMENT - COMPLIANCE SCHEDULE - BC 12.DOC Application Page 3 of 3
APPLICATION
I request that the compliance schedule for the above
building be amended as follows:
Specified System
Amendment
Reason
* (State why amendment is required to ensure that the specified system meets the performance
standards)
ATTACHMENTS
A c
opy of the existing compliance schedule is to be supplied with your application, along with any
other supporting documents.
.
Si
gnature of owner/agent on behalf of and with the authority of the owner.
...........................................................................
...........................................................................
Signature Date
click to sign
signature
click to edit
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