Construction Certificate Form - Oct 2012 - Richmond Valley Council

RICHMOND VALLEY COUNCILConstruction Certificate Application ChecklistThe checklist below identifies the information that may be required and will need to besubmitted with your applicationPlease tick all relevant boxes and attach information.PLEASE COMPLETE FORM IN BLACK INK3 copies of plans and 2 copies of specifications supplied (to scale)Details on application and plans have been suppliedWater Sensitive Urban DesignBasix Certificate – construction detailsWet area flashing details suppliedEngineer’s details:- (if required)Soil classification / borelog resultsSlab / FootingsBracing & tie down – including sizes & spansOtherSmoke detectors indicated on plans (if required)On-site Sewerage Management System application – 6 copies of Engineer’s ReportTermite protection methods suppliedBushfire protection measuresSpecifications of building work – construction detailsLong Service Levy ($25,000 and over)Builders licence on Construction Certificate application formOwner/Builders Permit (required for work over $5000)Copy of Insurance for residential work (if builder undertaking work)Disclosure of Political Donations and GiftsNote: If work is under $20,000 insurance is not needed. Machinery/farm sheds do not needinsurance. (Machinery/Farm Sheds not permitted on lots less than 2 ha)Pools:Water connection application formDetails for fencing, pump and backwash disposal suppliedCommercial/Industrial/Storage:Essential Fire Services to be installed / existingCopies of any compliance certificates / alternative solutionTO BE COMPLETED BY OWNERI have read all the information attached to this application and have completed the checklist above. Iacknowledge that the failure to supply all of the information requested by Council will result in theprocessing of this application being delayed.Print Name Signature Date

RICHMOND VALLEY COUNCILOffices: Cnr Walker Street & Graham Place, Casino19-25 Woodburn Street, Evans HeadPostal Address: Locked Bag 10, CASINO NSW 2470Email Address: council@richmondvalley.nsw.gov.auCasino Telephone: (02) 6660 0300Evans Head Telephone: (02) 6660 0365Construction Certificate Application(Environmental Planning and Assessment Act 1979 (As Amended))DA No________________Date _________________Amt $ ________________Receipt No ____________Prop No _____________(PLEASE COMPLETE FORM IN BLACK INK)Is this an Amended Construction Certificate? Yes No Oct 2012This application form is to be completed where a separate Development Application form has been completed (Generally used forIntegrated Development etc Applications)1. LandNo……………………... Street/Road…….…………………………………………………………………..…………Locality ………………….…………………………………………………………….……………………….………….Lot No……………………… Sec…..……..………. Deposited/Strata/ Plan No………...…………..………………2. ApplicantName(s) or Company .……………………………………………………………………………………..…………….Postal Address…………………………………………..…………………………......................................................…………………………………………………………………………………Postcode………………….……………...Telephone – Business….….………………Mobile…………..……………..…..Private………….…..……..………..Email Address…………………………………………………………………… Fax…………………….……..………Name (Print)…………………………………….………… Signature………………………..…………..…………….Date……………/…………../…………...3. Owner(s) of the Land and Owners ConsentAll owners must sign, attach separate sheet if required, provide the name of every owner - for company, body corporate orCrown land refer to page 4 of this formFamily Name(s) or Company ……………… …………...………….…………………………..…………..………….Given name(s) ………………………………..……………..……………………………………………………………Full Postal Address………………………………………..…………..………..........................................................…………………………………………………………………………………Postcode……….…..….…..……………Telephone – Business………….…………Mobile…………….……..….. Private…………...…..…………............Email Address…………………………………………………………… Fax………….……..……….……………** If signing on the owner's behalf as the owner's legal representative, you must state the nature of your legal authority andattach documentary evidence (eg, power of attorney, executor, trustee or company director).Name (Print)…………………………………….…………… Signature……………….………….………………….Name (Print)………………………………….……………... Signature………………….…….…………………….Date …….…..……./………...…../…………...- 1 -

4. Development TypeDescription of proposal for which development is sought (eg Dwelling, Alterations/Additions to ExistingDwelling, Carport, Garage, Swimming Pool, Retaining Wall etc)…………………………………………………………………………………………………………….……………….……………………………………………………………………………………………………………….…………….……………………………………………………………………………………………………………….…………….5. CostEstimated cost of the development $........................................................................................................(Please note that the cost must be a true market cost for the work, including all materials and labour costs –Estimate will be checked against current construction cost indices)6. Development Consent DetailsDevelopment Consent No………………………………………………………………………………….……………Date of Determination …………………………………………………………………………………...……………...7. Principal Certifying AuthorityAppointment of Principal Certifying AuthorityRichmond Valley CouncilPrivate Certifier (please complete details)Name ……………………………………………………………………….…………………….………………...…….Full Postal Address………………………………………………...................................................................…….………………………………………………………………………………..….…Postcode……………………………..Telephone – Business………....…………Mobile………..……..………....….. Private……………............……….Accreditation Authority ……………………………………………………………………………………………….….Accreditation No……………………..……..……….… Expiry Date ………………………….………………..……Company Issuing Indemnity Certificate ………………..……………..…………………………………………….…Expiry Date ………………….………………………- 2 -

8. Builder DetailsName…………………………………..…………………………………………………………………….…………….Full Postal Address…………………………………………………..…...................................................................…………………………………………………………………………..….………Postcode………….………..………Telephone – Business………………………Mobile……..…..……..…………..Private……………………………....Builders Licence No ……………………………..…………..…….. Expiry Date …..……/……………/………………Company Issuing Indemnity Certificate ………………………………….…………………………………………...Expiry Date ……………………..……………………(NB: PLEASE SUPPLY A COPY OF OWNER/BUILDER PERMIT WHEN OBTAINED)9. Building MaterialsBuilding Classification (from BCA) …………………………………………...………………………….……………..TYPES OF MATERIALS USED IN CONSTRUCTION OF THE BUILDINGFLOORS Concrete Timber Other ……………………EXTERNAL WALLS Full Brick Brick Veneer Timber CementMetal Concrete OtherROOF Metal Tiles Other ……………………FRAME DETAILS Metal TimberFloor area enclosed by external walls ……………………….m 2Number of storeys above each other ………………………..10. Disclosure StatementDisclosure of Political Donations and GiftsLegislation requires the disclosure of reportable political donations, made with the past two (2) years topolitical parties, elected members of NSW Parliament, Local Government elections and elected Councilmembers. This includes disclosure of gifts made to Councillors or Council employees, and any donation orgift made when a person was a candidate for Council election.Have you made a Political Donation or Gift Yes No(if ticked “Yes” a separate disclosure form must be completed.downloaded from the Department of Planning’s website)Forms are available at Council or- 3 -

PRIVACY & PERSONAL INFORMATION PROTECTION ACTThe personal information that council has collected from you is personal information for the purposes of the Privacy andPersonal Information protection Act, 1998.The intended recipients of the personal information are:• Officers within the Council;• Any other agent of the Council; and• Public sector agencies.The supply of the information by you is required by law. Failure to provide this information will prevent Council determiningthis matter.Council has collected this personal information from you in order to assist it in its determination of this matter. You may makeapplication for access or amendment to information held by Council. You may also make a request that Council suppressyour personal information from a public register. Council will consider any such application in accordance with the PPIPA.Council is to be regarded as the agency that holds the information.OWNER'S CONSENT - WHERE THE OWNER IS A COMPANYIf the owner of the land is a company, the company must sign as the owner. Section 127 of the Corporations Act 2001 detailshow a company may execute a document. This outlines the following requirements:A Company may execute a document without using a common seal if they document is signed by:• two (2) directors of the company; or• a director and a company secretary of the company; or• for a proprietary company that has a sole director who is also the sole company secretary - that director.Where the owner of the land is a company, and owner's consent is provided on documentation accompanying the form,Council requests that the names and positions held (e.g. Company Director) by those signing the form are clearly printedadjacent to the relevant signature(s).WHERE THE OWNER IS IDENTIFIED AS A BODY CORPORATEWhere the owner is identified as a Body corporate, the following is required:• Body Corporate Seal; and• A letter of consent signed by the Chairperson and Secretary.or• Body Corporate Seal; and• Body Corporate resolution consenting to the proposal (i.e. minutes of meeting where proposal was adopted);and• two (2) signatures, one of which must be the Chairperson.or• a signed letter of consent from each lot owner covered by the Body CorporateWHERE THE LAND IS IDENTIFIED AS CROWN LANDIf the land is Crown land, an authorised officer of the Department of Land and Water Conservation must sign the application- 4 -