F
orm 6 (Revision 6) Page 1 of 3
Last updated 18/3/2020
Queenstown Lakes District Council - Private Bag 50072 - Queenstown 9348 - Tel 03 441 0499 - www.qldc.govt.nz
Form 6
Application for Code Compliance Certificate
Section 92, Building Act 2004
1. PROJECT DETAILS
Building Consent Number
Issued by Queenstown Lakes District Council
2. THE OWNER
Name of Owner (Include preferred
title Mr, Miss, Mrs, Ms, Other)
Contact person (if not individually
owned, e.g., trust or company)
Address Mailing Street/registered office (if different)
Contact Details Phone Email
Evidence of ownership
As listed on building consent Agreement for sale and purchase
Certificate of Title Lease
Other document (must include full legal description e.g. rates)
3. AGENT (Only required if application is being made on behalf of owner)
Name of Agent (Include preferred
title Mr, Miss, Mrs, Ms, Other)
Contact person
Address
Mailing
Street/registered office (if different)
Contact Details
Ph
one Email
4. AUTHORISATION (Only required if application is being made on behalf of owner)
Relationship to owner (e.g. builder)
Confirm authorisation to act
Contact for communication
Owner
Agent
Other (please list details)
Form 6 (Revision 6) Page 2 of 3 Last updated 18/3/2020
5. APPLICATION
Completion Date
(Date all building work carried out
under the building consent specified on
this form was completed)
Restricted Building Work
Residential construction or alteration work affecting primary structure and weather-tightness
List licensed building practitioner(s) who carried out or supervised restricted building work (use separate page if necessary)
Name
LBP Number (or reg. no. (BA s291))
Work Carried out
Particular work carried out or supervised
#
#
#
#
#
Other Building Work
Personnel who carried out building work that is not restricted building work.
List names, addresses, telephone numbers, and (where relevant and if not provided above) licensed building practitioner
numbers or Plumbers, Gasfitters, and Drainlayers Board registration numbers (use separate page if necessary).
Name
Details
Trade, address, telephone, and registration number (where relevant and if not
provided above) included Builder or Principle Contractor, Sub-Contractors,
Plumbers, Gasfitters, Drainlayers etc.
Form 6 (Revision 6) Page 3 of 3 Last updated 18/3/2020
Specified Systems
Check your approved building consent for details and select one of the following
No Specified Systems Specified Systems as listed below
T
he following specified systems are contained on the compliance schedule for the building and, in the opinion of
the personnel who installed them, are capable of performing to the performance standards set out in the
building consent (use separate page if necessary).
SS Number e.g., SS2, SS4
Specified System Name
6. REQUEST TO ISSUE CCC
Attachments
Information requested on the issued building consent including:
Producer Statements Construction Review (PS4)
Producer Statement Construction (PS3
)
Certification (e.g. Gas & Electrical Certificates)
Records of work for restricted building work
Evidence for Specified Systems listed on the issued building consent
Other documents to assist with issue of CCC
I request that you issue a code compliance certificate (CCC) for this work under section 95 of the
Building Act 2004.
Name
(owner or agent on behalf of owner with the authority to act on their behalf)
Date
The Code Compliance Certificate should be emailed to: Agent Owner
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