Mens Shed Further Plans & Plumbing application

 

Version 8 — November 2014

Form 1—Compliance assessment application for plumbing, drainage and
on-site sewerage work

 

GENERAL NOTES

This form is to be used for the purposes of sections 85, 86 and 86A of the
Plumbing and Drainage Act 2002.

 

1. Type of application

Application for a compliance
permit or for a compliance
certificate.

yw Compliance permit (1 Compliance certificate
Compliance permit number (if applicable)

Date the work is proposed to commence

 

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Related approvals

 

 

 

 

 

2. Description of land
The description must identify
all land the subject of the
application.

Street address (include number, street, suburb/locality and postcode)

 

Schow! Sr emonwA

 

Postcode

 

Lot and plan: tAe (q2zo!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The lot and plan details (e.g. Shop/tenancy number Storey/level Local government area
SP/RP) are shown on title | | |
documents or a rates notice. (if applicable) (if applicable)
3. Applicant and owner Name (in full) t

details | Brant Larsson |
Identify who is making the Signature Date
application. The applicant
need not be the owner of the
land. dod , Contact person Phone number
In signing and lodging this
application, the applicant is SUsS 236s
responsible for ensuring the Mobile number Fax number Email address of applicant

information provided is true.
The local government will rely
on this information when
assessing the application.

 

lI 1

 

Postal address: y y4 ORAL AY RPerionA&

 

Owner's name if not the applicant: g Tore stk lors oO

 

Postal address of owner:

 

Email address of owner (if known)

 

 

 

 

4, Responsible person

The responsible person for
compliance assessable work is
a person who is licensed to
perform the work and either
performs or directs the
performance of the work.

If the responsible person for
the work is not known, a
signature in this partis not
required, However, if this
section is not signed a Form 7
must be completed by the
responsible person and
provided to the local
government prior to requesting
an assessment of the work.

Name (in full)

[7BA

Plumbing Industry Council licence number QBSA licence number (if applicable)

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Phone number Mobile number Fax number
Email address of responsible person
Postal address

Postcode
Signature Date

 

 

 

 

 

 

 

5. Sanitary plumbing
and sanitary drainage

This section is mandatory if
there is sanitary plumbing
and/or drainage work involved.

 

If the application is for sanitary plumbing and/or drainage work, provide details of the
proposed work

new [alteration
Details (e.g. relocating WC)

 

 

 

The Plumbing and Drainage Act 2002 is administered
by the Department of Housing and Public Works