Fillable D19 23031 Exempt Building Work Template

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D19 23031 Exempt Building Work Template

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D19/23031 Exempt building Works Template
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)
Legal 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)
Current Lawfully Established Use:
THE OWNER
Name of Owner:
(Include preferred form of address, eg: Mr, Miss, full name, mailing address, phone number(s), and email address/es).
Contact Person:
Mailing Address:
Phone:
Mobile:
Email Address:
THE AGENT
Name of Agent:
(Only required if application is being made on behalf of the owner)
First Point of Contact for Communications with the Council:
(State full name, mailing address, phone number(s), and email address/es).
Mailing Address:
Street Address/Registered Office:
Phone:
Mobile:
Email Address:
APPLICATION TO EXEMPTED BUILDING WORKS
Schedule 1 exempt work
Parts 1, 2, & 3 Building Act 2004
D19/23031 Exempt building Works Template
DESCRIPTION OF BUILDING WORK TO BE EXEMPTED
Part Number and Exemption Number
(Refer to the Ministry of business innovation & employment guidance hand book)
Work to be exempt (Provide details of building work to be exempt)
Documentation to support Exemption:
(Provide details of)
Building code clauses that will comply to
All workers LPB Details
Plans and specification
Supporting Asbestos documentation including WorkSafe Notification Number
Signature of owner/agent on behalf of and with the authority of the owner.
Signature:
Date:
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D19 23031 Exempt Building Work Template

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Completed 2 July 2020

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