Waimakariri District Council
170524052747 [v01]
V1 -
1/01/2018
1 of 2 Application for a Waiver or Modication to a Specic Clause in the Building Code
APPLICATION FOR A WAIVER OR MODIFICATION
TO A SPECIFIC CLAUSE OF THE BUILDING CODE
Under The Building Act 2004, Sections 67
BC No.
Private Bag 1005, Rangiora 7440
Phone 0800 965 468 (0800 WMK GOV)
Fax 03 313 4432 - waimakariri.govt.nz
PART 1 - APPLICATION
1. Building consent number to which this waiver or modication relates:
THE AGENT
PLEASE NOTE - Authorisation is required from the owner to act as agent.
12.
Agent’s name:
(Company or Organisation name if applicable)
13.
Contact person:
14. Mailing address:
15. Street address / Registered office:
16. Mobile: Landline:
Email:
THE BUILDING (Project location)
Valuation Number:
2. Site address:
(Street / Road / T
ownship)
3. Legal description of the land where the building is located:
Lot:
DP:
4. Building Name (if applicable):
5. Location of building within site:
(Only applicable to multi-development sites)
6. Level/unit number to which amendment relates (if applicable):
THE OWNER
7. Owner’s name:
(Company or organisation name if applicable)
8.
Contact person:
9. Mailing address:
10. Street address / Registered office:
11. Mobile: Landline:
Email:
COUNCIL USE ONLY
Application #: Property ID :
Waimakariri District Council
170524052747 [v01]
V1 -
1/01/2018
2 of 2 Application for a Waiver or Modication to a Specic Clause in the Building Code
PART 2 - DETAILS
1 7. Description of waiver or modication:
Identify the specic clause of the building code to which this application for a waiver or modication has been requested
State the reasons as to why a waiver or modication has been requested and why compliance with the building code
cannot be achieved:
OWNER / AGENT AUTHORISATION
PLEASE NOTE - By entering your name in the box below you are giving your authority for the application to proceed.
Name:
Date:
I am the
Owner
Agent
Note: If acting on behalf, by entering your name above you hereby declare that you are authorised to act as Agent for
the Owner.
NB: Ensure Agent Authorisation section is completed - see below.
AGENT AUTHORISATION
(TO BE AUTHORISED BY OWNER)
PLEASE NOTE - By entering your name in the box below you are giving your authority for this application to proceed.
I authorise
to act as Agent on my behalf for this
Building Consent application under Sections 33 and 45 of the Building Act 2004.
With respect to this Building Consent application, I authorise
to act
as Agent on my behalf for the application for Code Compliance Certicate under Section 92 of the Building Act 2004.
Name (Owner): Date:
PRIVACY INFORMATION
The information you have provided on this form is required so that your building consent 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.
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