Certificate for Public Use Application Form

The personnel who carry out the building work are as follows:[If known, list names, addresses, phone numbers, and (where relevant) registration numbers]Designer/Architect:Business/name:Address:Structural Engineer:Business/name:Address:Daytime: Mobile: Daytime: Mobile:After hours: Facsimile: After hours: Facsimile:Registration/qualification:Registration/qualification:Engineer (identify practice college):Business/name:Address:Plumber:Business/name:Address:Daytime: Mobile: Daytime: Mobile:After hours: Facsimile: After hours: Facsimile:Registration/qualification:Registration/qualification:Builder:Business/name:Address:Drainlayer:Business/name:Address:Daytime: Mobile: Daytime: Mobile:After hours: Facsimile: After hours: Facsimile:Registration/qualification:Registration/qualification:Head Contractor / Site Manager:Business/name:Address:Other:Business/name:Address:Daytime: Mobile: Daytime: Mobile:After hours: Facsimile: After hours: Facsimile:Registration/qualification:Registration/qualification:I request that you issue, under section 363A(2) of the Building Act 2004, a certificate for public use for thepremises or the part of the premises described above.Signature of the owner / occupier / person in control ofpremises / agent on behalf of, and with the authority of,the owner / occupier / person in control of premises:Name of person signing:Date:164919 v2B Form 15 Application for Public Use Certificate September 2009