PO Box 5035
7
th
Floor, City Hall
London ON N6A 4L9
BCIN: 18458
Schedule 1: Designer Information
Use one form for each individual who reviews and takes responsibility for design activities with respect to the project.
A. Project Information
Building number, street name Unit no. Lot/con.
Municipality Postal code Plan number/ other description
B. Individual who reviews and takes responsibility for design activities
Name Firm
Street address Unit no. Lot/con.
Municipality Postal code Province E-mail
Telephone number
( )
Fax number
( )
Cell number
( )
C. Design activities undertaken by individual identified in Section B. [Building Code Table 3.5.2.1 of
Division C]
House
Small Buildings
Large Buildings
Complex Buildings
HVAC – House
Building Services
Detection, Lighting and Power
Fire Protection
Building Structural
Plumbing – House
Plumbing – All Buildings
On-site Sewage Systems
Description of designer’s work
D. Declaration of Designer
I ___________________________________________________________________ declare that (choose one as appropriate):
(print name)
I review and take responsibility for the design work on behalf of a firm registered under subsection 3.2.4 of Division
C. of the Building Code. I am qualified, and the firm is registered, in the appropriate classes/categories.
Individual BCIN: _________________________________
Firm BCIN: _________________________________
I review and take responsibility for the design work and am qualified in the appropriate category as an “other
designer” under subsection 3.2.5 of Division C, of the Building Code.
Individual BCIN: _________________________________
Basis for exemption from registration: ___________________________________
The design work is exempt from the registration and qualification requirements of the Building Code.
Basis for exemption from registration and qualification:__________________________________________
I certify that:
1. The information contained in this schedule is true to the best of my knowledge.
2. I have submitted this application with the knowledge and consent of the firm.
________________________________ _________________________________________________________________
Date Signature of Designer
NOTE:
1. For the purposes of this form, “individual” means the “person” referred to in Clause 3.2.4.7.(1) d). of Division C, Article 3.2.5.1 of Division C,
and all other persons who are exempt from qualification under Subsections 3.2..4. and 3.2.4 of Division C.
2. Schedule 1 is not required to be completed by a holder of a license, temporary license, or a certificate of authorization, issued by the Ontario
Association of Architects. Schedule 1 is also not required to be completed by a holder of a license to practise, a limited license to practise, or a
certificate of authorization, issued by the Association of Professional Engineers of Ontario.
Form no 0840 (rev.2011.01) www.london.ca
