This agreement is made on [insert date]

This agreement is made between—

[insert full name and address]

(commercial on-seller)

and

[insert full name and address]

(purchaser)

(together the parties)

The commercial on-seller and the purchaser have entered or intend to enter into a contract for the sale and purchase of [insert street address of household unit] (household unit) dated [insert date of contract, if any] (contract).

As at the date of this agreement, a building consent has been granted in relation to the household unit but a code compliance certificate has not been issued.

Section 362V(1) of the Building Act 2004 (Act) provides that a commercial on-seller commits an offence if that commercial on-seller completes a sale of the household unit or allows the purchaser into possession of the household unit before a code compliance certificate has been issued for the household unit, unless the parties enter into an agreement in accordance with section 362V(2) of the Act.

The parties wish to enter into this agreement under section 362V(2) of the Act to enable the commercial on-seller to complete a sale of the household unit or to allow the purchaser of the household unit to enter into possession of the household unit before a code compliance certificate has been issued in relation to the household unit.

*Delete if inapplicable.

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]

Building name:

Location of building within site/block number: [include nearest street access]

Number of levels: [include ground level and any levels below ground]

Level/unit number:

Area: [total floor area; indicate area affected by the building work if less than the total area]

Current, lawfully established, use: [include number of occupants per level and per use if more than 1]

Year first constructed:

Name of owner: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

The following evidence of ownership is attached to this application: [copy of record of title, lease, agreement for sale and purchase, or other document showing full name of legal owner(s) of the building]

†Name of agent: [only required if application is being made on behalf of the owner]

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Relationship to owner: [state details of the authorisation from the owner to make the application on the owner’s behalf]

First point of contact for communications with the council/building consent authority: [state full name, mailing address, phone number(s), facsimile number(s) and email address(es)‡]

I request that you issue a †project information memorandum/†project information memorandum and building consent/†building consent for the building work described in this application.

Signature of †owner/†agent on behalf of and with the authority of the owner:

Date:

Description of the building work:

Will the building work result in a change of use of the building?

†Yes/†No

†If Yes, provide details of the new use:

Intended life of the building if less than 50 years: . years

List building consents previously issued for this project (if any):

Estimated value of the building work on which the building levy will be calculated (including goods and services tax): $ [state estimated value as defined in section 7 of the Building Act 2004]

Will the building work include any restricted building work?

*Yes/*No

*If Yes, provide the following details of all licensed building practitioners who will be involved in carrying out or supervising the restricted building work [If these details are unknown at the time of the application, they must be supplied before the building work begins.]:

Note: Continue on another page if necessary.

The following matters are involved in the project:

†Subdivision

†Alterations to land contours

†New or altered connections to public utilities

†New or altered locations and/or external dimensions of buildings

†New or altered access for vehicles

†Building work over or adjacent to any road or public place

†Disposal of stormwater and wastewater

†Building work over any existing drains or sewers or in close proximity to wells or water mains

†Other matters known to the applicant that may require authorisations from the territorial authority: [specify]

¶The following plans and specifications are attached to this application:

The building work will comply with the building code as follows:

†The specified systems for the building are as follows: [specified systems are defined in regulations]

†The following specified systems are being altered, added to, or removed in the course of the building work:

†There are no specified systems in the building.

The following documents are attached to this application:

†Plans and specifications [list]

†Alternative plans and specifications (if the applicant wants to obtain pre-approval for possible product substitutions) [list]

†Current product certificate(s)

†Alternative product certificate(s) (if the applicant wants to obtain pre-approval for possible product substitutions)

†Current manufacturer’s certificate(s) referred to in section 45(1)(bb) of the Act

†Current manufacturer’s certificate(s) referred to in section 45(1)(bc) of the Act

†Memoranda from licensed building practitioner(s) who carried out or supervised any design work that is restricted building work

†Project information memorandum

†Development contribution notice

†Certificate attached to project information memorandum

*Delete if the applicant is an individual.

†Delete if inapplicable.

‡Contact details must be in New Zealand.

§Delete this section if this is an application for a building consent only.

║Delete this section if this is an application for a project information memorandum only.

¶All plans and specifications must meet the minimum requirements set out in the regulations or required by the building consent authority.

Street address of building:

Name:

Address:

Telephone number:

Email address:

I carried out/supervised the following design work that is restricted building work:

Are waivers or modifications of the building code required?: Yes/No

If yes, provide details of the waivers or modifications below:

[Name of licensed building practitioner who is licensed to carry out or supervise design work that is restricted building work]

†Licensed building practitioner number [if applicable]:

†Registered architect number [if applicable]:

†Chartered professional engineer number [if applicable]:

Mailing address:

Street address or registered office:

Telephone number:

Mobile number:

Daytime number:

After hours number:

Fax number:

Email address:

Internet site:

I, [name of licensed building practitioner], certify that the design work that is restricted building work recorded on this form—

Street address of building:

Name:

Address:

Telephone number:

Email address:

Note: Complete the following section if this form is attached to an application for a building consent that is accompanied by plans or specifications containing design work that is restricted building work that has been carried out by the owner-builder (section 45(5)(b) of the Building Act 2004).

The design work that is restricted building work that I, [name, place of abode, occupation], carried out as an owner-builder is—

*all of the design work that is restricted building work described in the attached application for a building consent; or

*the design work that is restricted building work as set out below:

Note: The following section is to be completed if—

The building work that is restricted building work that I, [name, place of abode, occupation], intend to carry out as an owner-builder is—

*all of the building work that is restricted building work described in the attached application for a building consent

or

*the building work that is restricted building work as set out below:

I, [name, place of abode, occupation], am an owner-builder for the purposes of the Building Act 2004 as I—

Defined terms

relevant interest, in relation to the land or the building on which restricted building work is to be carried out, means a legal or equitable interest in the land or building and includes—

reside includes temporarily reside.

I, [name, place of abode, occupation], solemnly and sincerely declare that the statements contained in this form are true, and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

Building consent number:

Issued by: [name of building consent authority that granted building consent]

Name:

Address:

Telephone number:

Email address:

Name of agent: [only required if notification is being given on behalf of the owner]

†Contact person:

Mailing address:

Street address/registered office:

Telephone number:

Mobile number:

Daytime number:

After hours number:

Fax number:

Email address:

Internet site:

Relationship to owner: [Specify details of authorisation from the owner to give the notification on the owner’s behalf]

First point of contact for communications with the building consent authority: [full name, mailing address, telephone number(s), fax number(s) and email address(es)‡]

I, [name, place of abode, occupation], give notice under section 87A of the Building Act 2004 that—

*I intend to carry out restricted building work under the owner-builder exemption, but did not include a statutory declaration to that effect with my application for a building consent.

or

*There has been a change in the owner-builder carrying out the restricted building work. I intend to carry out restricted building work under the owner-builder exemption, and attach a statutory declaration to that effect.

or

*I have ceased to carry out some or all of the restricted building work under the owner-builder exemption.

If the notice affects some but not all of the restricted building work identified in the application for the building consent, please include details on a separate page.

Statutory declaration as to owner-builder status (form 2B).

To: [name and address of owner]

A code compliance certificate for the building work referred to in the attached project information memorandum will not be issued until a development contribution of $. is paid. The development contribution must be paid to [name of territorial authority and address of place/s where payment can be made].

If the development contribution is not paid,—

Signature:

Position:

On behalf of: [name of Council]

Date:

The building work referred to in the attached project information memorandum is also required to have the following resource consents under the Resource Management Act 1991:

[list resource consents required]

As these resource consents will or may materially affect the building work to which the attached project information memorandum relates, until they have been granted *no building work may proceed/*building work may only proceed to the extent stated below:

Failure to comply with the requirements of this notice may result in legal action being taken against you under the Resource Management Act 1991.

Signature:

Position:

On behalf of: [name of Council]

Date:

*Delete if inapplicable.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Name of owner:

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

First point of contact for communications with the building consent authority: [state full name, mailing address, and any phone number(s), facsimile number(s), and email address(es)†]

The following building work is authorised by this building consent:

This building consent is issued under section 51 of the Building Act 2004. This building consent does not relieve the owner of the building (or proposed building) of any duty or responsibility under any other Act relating to or affecting the building (or proposed building). This building consent also does not permit the construction, alteration, demolition, or removal of the building (or proposed building) if that construction, alteration, demolition, or removal would be in breach of any other Act.

‡This building consent is subject to the following conditions:

A compliance schedule ‡is/‡is not required for the building.

‡The compliance schedule must contain the following specified systems and comply with the performance standards for those systems required by the building code: [list required systems]

Copies of the following documents are attached to this building consent:

‡Project information memorandum number .

‡Development contribution notice

‡Certificate attached to project information memorandum

Signature:

Position:

On behalf of: [name of building consent authority]

Date:

*Delete if the applicant is an individual.

†Contact details must be in New Zealand.

‡Delete if inapplicable.

§Delete if the building is intended to have a life of 50 years or more.

Building consent number:

Issued by: [name of building consent authority that granted building consent]

Name of owner: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

†Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

The following evidence of ownership is attached to this application: [copy of record of title, lease, agreement for sale and purchase, or other document showing full name of legal owner(s) of the building]

Name of agent: [only required if application is being made on behalf of the owner]

§Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Relationship to owner: [state details of authorisation from the owner to make the application on the owner’s behalf]

First point of contact for communications with the building consent authority: [state full name, mailing address, phone number(s), facsimile number(s) and email address(es)║]

All building work to be carried out under the building consent specified on this form was completed on [insert date].

The licensed building practitioner(s) who carried out or supervised the restricted building work is/are as follows:

The personnel who carried out building work other than restricted building work are as follows: [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]

Note: Continue on another page if necessary.

The 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:

[list specified systems]

I request that you issue a code compliance certificate for this work under section 95 of the Building Act 2004.

The code compliance certificate should be sent to: [state which address, and whether owner or agent]

Signature of ¶owner/¶agent on behalf of and with the authority of the owner:

Name of person signing:

Date:

The following documents are attached to this application:

¶Other documents from the personnel who carried out the work

†Memoranda from licensed building practitioner(s) stating what restricted building work they carried out or supervised

¶Certificates that relate to the energy work

¶Evidence that specified systems are capable of performing to the performance standards set out in the building consent

¶Current manufacturer’s certificate, if applicable

*Delete this section if details have not changed from the building consent.

†Delete if owner is an individual.

‡Delete this section if the application is not being made on behalf of the owner.

§Delete if the agent is an individual.

║Contact details must be in New Zealand.

¶Delete if inapplicable.

Street address of building:

Building consent number:

Name:

Address:

Telephone number:

Email address:

[Name of licensed building practitioner who is licensed to carry out or supervise restricted building work]

†Licensed building practitioner number [if applicable]:

Class(es) licensed in:

†Plumbers, Gasfitters, and Drainlayers Board registration number [if applicable]:

Mailing address:

Street address or registered office:

Telephone number:

Mobile number:

Daytime number:

After hours number:

Fax number:

Email address:

Internet site:

I, [name of licensed building practitioner], carried out or supervised the restricted building work recorded on this form.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Current, lawfully established, use: [include number of occupants per level and per use if more than 1]

Year first constructed:

Name of owner:

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

First point of contact for communications with the building consent authority: [state full name, mailing address, phone number(s), facsimile number(s), and email address(es)†]

Building consent number:

Issued by: [name of building consent authority that issued the building consent]

The building consent authority named below is satisfied, on reasonable grounds, that—

‡Compliance schedule

Signature:

Position:

On behalf of: [name of building consent authority]

Date:

*Delete if the applicant is an individual.

†Contact details must be in New Zealand.

‡Delete if inapplicable.

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]

Building name:

Location of building within site/block number: [include nearest street access]

Number of levels: [include ground level and any levels below ground]

Level/unit number:

Area: [total floor area—indicate area affected by the building work if less than the total area]

Current, lawfully established, use: [include number of occupants per level and per use if more than 1. If use was changed by the building work this application relates to, state previous use.]

Year first constructed:

Name of owner: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

The following evidence of ownership is attached to this application: [copy of record of title, lease, agreement for sale and purchase, or other document showing full name of legal owner(s) of the building]

Name of agent: [only required if application is being made on behalf of the owner]

‡Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Relationship to owner: [state details of authorisation from owner to make the application on the owner’s behalf]

First point of contact for communications with the council: [state full name, mailing address, phone number(s), facsimile number(s) and email address(es)§]

I request that you issue a certificate of acceptance for the building work described in this application.

Signature of ║owner/║agent on behalf of and with the authority of the owner:

Date:

Description of the building work:

Date building work carried out:

The personnel who carried out the building work are as follows: [list names, addresses, phone numbers, and (where relevant) registration numbers]

Did the building work result in a change of use of the building?

║Yes/║No

║If Yes, provide details of the new use:

Intended life of the building if 50 years or less: . years

List building consents previously issued for this project (if any):

¶Estimated value of the building work on which building levy will be calculated (including goods and services tax): $ [state estimated value as defined in section 7 of the Building Act 2004]

**The following plans and specifications are attached to this application:

Reasons why a certificate of acceptance is required:

║The owner, or the owner’s predecessor in title, carried out building work for which a building consent was required, but a building consent was not obtained because: [explain in detail]

║A building consent could not practicably be obtained in advance because the building work had to be carried out urgently: [delete one of the following]

║The building consent authority that granted the building consent is unable or refuses to issue a code compliance certificate in relation to the building work, and no other building consent authority will agree to issue a code compliance certificate for the building work: [state details of name of building consent authority and building consent granted]

║The specified systems for the building are as follows: [specified systems are defined in regulations]

║The following specified systems were altered, added to, or removed in the course of the building work:

║There are no specified systems in the building.

The following are attached to this application:

║Project information memorandum

║Plans and specifications

║Certificates from personnel who carried out the building work

║Energy work certificate

*Delete if the applicant is an individual.

†Delete this section if the application is not being made on behalf of the owner.

‡Delete if the agent is an individual.

§Contact details must be in New Zealand.

║Delete if inapplicable.

¶Delete if inapplicable, only applies if an application for a certificate of acceptance is made under section 96(1)(a) of the Building Act 2004.

**All plans and specifications must meet the minimum requirements set out in the regulations or any other requirements of the building consent authority.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Name of owner:

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

First point of contact for communications with the council: [state full name, mailing address, phone number(s), facsimile number(s) and email address(es)†]

The territorial authority named below is satisfied, to the best of its knowledge and belief and on reasonable grounds, that, insofar as it can ascertain, the building work described below complies with the building code:

‡The territorial authority was only able to inspect the following parts of the building work and this certificate is qualified as follows:

Nothing in this certificate limits the requirement that a person must not carry out building work except in accordance with a building consent, nor does it relieve any person from the requirement to obtain a building consent for building work.

‡Compliance schedule

Signature:

Position:

On behalf of: [name of territorial authority]

Date:

*Delete if the owner is an individual.

†Contact details must be in New Zealand.

‡Delete if inapplicable.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Current, lawfully established, use:

Year first constructed:

Name of owner:

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

The following specified systems are covered by the compliance schedule for this building:

The compliance schedule is kept at:

Signature:

Position:

On behalf of: [name of territorial authority]

Date:

This statement is valid for 12 months after the date stated above.

*Delete if the owner is an individual.

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]

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 1]

Name of owner: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Evidence of ownership: [copy of record of title, lease, agreement for sale and purchase, or other document showing full name of legal owner(s) of the building]

Name of agent: [only required if application is being made on behalf of the owner]

‡Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Relationship with owner: [state details of authorisation from owner to make the application on the owner’s behalf]

First point of contact for communications with the council: [state full name, mailing address, phone number(s), facsimile number(s) and email address(es)§]

I request that the compliance schedule for the above building be amended as follows:

Copy of existing compliance schedule

Signature of ║owner/║agent on behalf of, and with the authority of, the owner:

Date:

*Delete if the owner is an individual.

†Delete this section if the application is not being made on behalf of the owner.

‡Delete if the agent is an individual.

§Contact details must be in New Zealand.

║Delete if inapplicable.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Current, lawfully established, use: [include number of occupants per level and per use if more than 1]

Year first constructed:

Intended life of the building if 50 years or less: . years

Highest fire hazard category for building use: [state number]

Name of owner:

*Contact person:

Mailing address:

Street address/registered office:

Phone number:

Landline:

Mobile:

Daytime:

After hours:

Facsimile number:

Email address:

Website:

Name of agent: [only required if warrant is being supplied on behalf of the owner]

§Contact person:

Mailing address:

Phone number:

Daytime:

After hours:

Facsimile number:

Email address:

Relationship to owner: [state details of authorisation from the owner to supply the warrant on the owner’s behalf].

†The maximum number of occupants that can safely use this building is:

The inspection, maintenance, and reporting procedures of the compliance schedule for the above building have been fully complied with during the 12 months prior to the date stated below.

The compliance schedule is kept at:

†Certificates relating to inspections, maintenance, and reporting

†Recommendations for amendments to the compliance schedule

Signature of †owner/†agent on behalf of and with the authority of the owner:

Date:

*Delete if the owner is an individual.

†Delete if inapplicable.

‡Delete this section if the warrant is not being supplied on behalf of the owner.

§Delete if the agent is an individual.

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

Name of owner:

*Contact person:

Mailing address:

Street address:

†Registered office:

The inspection, maintenance, and reporting procedures of the compliance schedule have been fully complied with during the 12 months prior to the date stated below in relation to the following specified system/s:

[state specified system(s)].

Signature of licensed building practitioner:

*Delete if applicant is individual.

†Delete if inapplicable.

To: [name and address of owner]

*And to: [name and address of person carrying out or supervising the building work]

Street address of building:

Legal description of land where building is located:

Building name:

Location of building within site/block number:

Level/unit number:

[Insert details of failure or error with reference to any relevant building consent]

To remedy the contravention or non-compliance you must: [state any building work that must be carried out and whether a certificate of acceptance must be applied for]

This notice must be complied with by: [date or time frame]

*You must contact the [state whether the persons to whom the notice is given must contact the territorial authority for the district within which the building is situated, the regional authority for the region within which the building is situated, or both] on completion of the required building work.

*All building work must cease immediately until the authority that issued this notice is satisfied that you are able and willing to resume operations in compliance with the Building Act 2004 and regulations under that Act.

*The following building work must cease immediately until the authority that issued this notice is satisfied that you are able and willing to resume operations in compliance with the Building Act 2004 and regulations under that Act: [insert details of building work]

If you do not comply with this notice you commit an offence under section 168 of the Building Act 2004 and may be liable to a fine of up to $200,000 and a further fine of up to $20,000 for each day or part of a day that you fail to comply with this notice.

Signature:

Position:

On behalf of: [name of territorial authority]

Date:

*Delete if inapplicable.

Name: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

*Contact person:

Mailing address:

Phone number:

Email address:

The applicant is:

†The owner of the building

†The territorial authority of the district in which the building is located

†The building consent authority responsible for consenting to the building work

†The licensed building practitioner concerned with the relevant building work

†The owner of other property (as defined in section 7 of the Building Act 2004) affected by the building work [include details of the property so affected: street address and legal description and the provision of the building code that requires the property to be protected]

†The regional authority of the region in which the dam is located

†A person who has a direct interest in the matter for determination if the matter for determination relates to the provision of access and facilities for persons with disabilities [state the nature of the direct interest]

†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [state details of the relevant right or obligation]

The other parties to this application are [state names and mailing addresses]:

†The owner of the building

†The territorial authority of the district in which the building is located

†The building consent authority responsible for consenting to the building work

†The licensed building practitioner concerned with the relevant building work

†The regional authority of the region in which the dam is located

†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [give details of the relevant right or obligation]

Copies of this application have been sent to all the above-named parties.

Street address: [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/†dam 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/†Dam name:

Current, lawfully established, use: [include number of occupants per level and per use if more than 1]

Year first constructed:

I apply for a determination in relation to the following matter/s: [include, for each applicable item, all relevant details, including any reasons given by the building consent authority, territorial authority, or regional authority for its decision]

The following applications have been made and are related to this application [give date of application and name of applicant]

The following documents are attached to this application: [list plans, specifications, other documents, and correspondence provided in support of this application]

†I wish to give written/spoken evidence in te reo Māori.

Signed by the applicant:

‡Name and position (print):

Date:

*Delete if the applicant is an individual.

†Delete if inapplicable.

‡Only required if applicant is not an individual and application is signed by an authorised officer or agent of the applicant.

Name: [include preferred form of address, eg, Mr, Ms, Dr, if an individual]

*Contact person:

Mailing address:

Phone number:

Email address:

The applicant is:

†The owner of the building

†The territorial authority of the district in which the building is located

†The building consent authority responsible for consenting to the building work

†The licensed building practitioner concerned with the relevant building work

†The owner of other property (as defined in section 7 of the Building Act 2004) affected by the building work [include details of the property so affected: street address and legal description and the provision of the building code that requires the property to be protected]

†The regional authority of the region in which the dam is located

†A person who has a direct interest in the matter for determination if that matter relates to the provision of access and facilities for persons with disabilities [state the nature of the direct interest]

†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [state details of the relevant right or obligation]

†A responsible person (as defined in section 133BB of the Building Act 2004, but not including the people specified in section 177(6) of that Act)

The other parties to this application are [state names and mailing addresses]:

†The owner of the building

†The territorial authority of the district in which the building is located

†The building consent authority responsible for consenting to the building work

†The licensed building practitioner concerned with the relevant building work

†The regional authority of the region in which the dam is located

†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [give details of the relevant right or obligation]

†A responsible person (as defined in section 133BB of the Building Act 2004, but not including the people specified in section 177(6) of that Act)

Copies of this application have been sent to all the above-named parties.

Street address: [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/†dam 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/†Dam name:

Description of †building/†dam: [describe the building or dam, including, for example, its use, size, construction type, number of occupants]

Current state of †building/†dam: [describe the state of the building, including, for example, how it has been affected by the emergency]

Year first constructed:

I apply for a determination in relation to the decision of the responsible person—

Key details relevant to decision: [for each decision, give all details relevant to the decision (include dates and times of key events). If the responsible person gave reasons for the decision, state the reasons. If no reasons were given, state that no reasons were given.]

Reasons for application: [for each decision, set out the reasons the decision did not comply with the Building Act 2004 or was otherwise wrong]

The following applications have been made and are related to this application [give date of application and name of applicant]

The following documents are attached to this application:

†I wish to give written/spoken evidence in te reo Māori.

Description of *premises/*part of premises for which certificate is sought: [identify the building in which the premises or part of the premises are located and describe those premises or that part of the premises. If appropriate, provide plans or diagrams that clearly delineate the premises or part of the premises.]

Building *consent number/*consent numbers:

Issued by: [name of building consent authority that issued the building consent]

Name of applicant: [include preferred form of address, eg, Mr, Miss, Dr, if an individual]

†Contact person:

Mailing address:

Phone number:

Daytime:

After hours:

Facsimile number:

Email address:

The applicant is the person who *owns/*occupies/*controls the premises.

The following evidence of the applicant’s status as *owner/*occupier/*person in control is attached to this application: [eg, copy of record of title, lease, agreement for sale and purchase, licence, or property management agreement, being a document that shows the full name of the applicant]

‡The owner’s name and address is: [state owner’s name and address]

Name of agent: [only required if application is being made on behalf of the owner, occupier, or person in control of premises]

║Contact person:

Mailing address:

Phone number:

Daytime:

After hours:

Facsimile number:

Email address:

Relationship to *owner/*occupier/*person in control of the premises: [state details of authorisation from the *owner/*occupier/*person in control of premises to make the application on the person’s behalf]

I confirm that no code compliance certificate has been issued for the building work.

It is intended to permit members of the public to use the *premises/*part of the premises described above for the following purposes and in the following circumstances: [describe purposes and circumstances]

Members of the public can use the *premises/*part of the premises described above safely because: [state reasons for statement, and include any precautions taken to protect the public, information on any specified systems in the premises or part of the premises, and the management of any special risks (eg, means of escape from fire) on site (provide information in attachments, if necessary)]

The personnel who carry out the building work are as follows: [if known, list names, addresses, phone numbers, and (where relevant) registration numbers]

I request that you issue, under section 363A(2) of the Building Act 2004, a certificate for public use for the premises or the part of the premises described above.

Signature of *owner/*occupier/*person in control of premises/*agent on behalf of, and with the authority of, the *owner/*occupier/*person:

Name of person signing:

Date:

The following documents are attached to this application:

*Evidence of applicant’s status

*Plans and diagrams showing the premises or part of the premises described above

*Documentation relevant to the safety of the *premises/*part of the premises (eg, an engineer’s report, certificates concerning specified systems)

*Delete if inapplicable.

†Delete if owner/occupier/person in control is an individual.

‡Delete if the applicant is the owner.

§Delete this section if the application is not being made on behalf of the owner/occupier/person in control.

║Delete if the agent is an individual.

Description of *premises/*part of premises for which certificate is issued: [identify the building in which the premises or part of the premises are located and describe those premises or that part of the premises. If appropriate, refer to plans or diagrams that clearly delineate the premises or part of the premises.]

Building *consent number/*consent numbers:

Issued by: [name of building consent authority that issued the building consent]

Name and description of applicant: [state whether applicant owns, occupies, or controls the premises]

†Contact person:

Mailing address:

Phone number:

Daytime:

After hours:

Facsimile number:

Email address:

The territorial authority named below, being satisfied on reasonable grounds, in relation to the building work described above, that members of the public can safely use the *premises/*part of the premises described above, issues under section 363A(2) of the Building Act 2004 this certificate for public use in respect of *those premises/*that part of the premises. *This certificate is subject to the following conditions: [state conditions]

Nothing in this certificate limits the duty of the owner to apply for a code compliance certificate, nor does it relieve any person from compliance with any other legislative requirement.

The following documents are attached to this application:

*Plans and diagrams showing the premises or part of the premises in respect of which the certificate is issued

*Any other documentation the territorial authority considers relevant to the territorial authority’s certificate

Signature:

Position:

On behalf of: [name of territorial authority]

Date:

*Delete if inapplicable.

†Delete if applicant is an individual.