Application for Private Certification Services - City of Perth

CERTIFICATION SERVICESBuilding ActPrivacyThe personal information collected on this form will only beused by the City of Perth for the sole purpose of providingrequested and related services. Information will be storedsecurely by the City and will not be disclosed to any thirdparties without your express written consent.CopyrightI authorise the City of Perth to reproduce any attachmentsprovided with this form for internal purposes only.City of PerthCouncil House27 St George’s Terrace, PerthGPO Box C120 PerthWestern Australia 6839ABN 8378 0118 628Phone: (08) 9461 3366Facsimile: (08) 9461 3082building@cityofperth.wa.gov.auwww.perth.wa.gov.auGeneral1. The purpose of this form is to apply for a cost estimate from the City of Perth for thesupply of building surveying certification services. These services are providedthroughout Western Australia.2. Please allow a minimum of 3 days for applications to be processed. Applications for aquotation can be submitted via email to building@cityofperth.wa.gov.au only or over thecounter at Customer Service located on the ground floor of Council House.3. Instructions for submitting an application will be provided on your cost estimate.1. APPLICANT DETAILSCompany Name:Surname: First Name:Postal Address:Postcode:Telephone:Mobile:Facsimile:Email:2. PROPERTY LOCATION OF PROPOSED WORKSLot No:Plan No:Unit No: Level: Street No:Street Name:Suburb:State: WA Postcode:

3. Nature of Proposed Building Work:Project Name:Description of Works:Alteration/Additions Fit out Garage Patio/Carport New DwellingShed Swimming Pool/Spa Change of Use/Conversion, proposed use _________Other, please specify ___________________________________________Are there any current approvals associated with the proposed works?NO YES Application No/s: ___________________________________4. CERTIFICATION SERVICE REQUIREDCertificate of Design Compliance (includes DFES referral):Certificate of Construction Compliance - BA No / :Certificate of Building Compliance (includes DFES referral if required) - BA No / :5. BUILDING CLASSIFICATION (Current )Class 1A Single dwelling being detached or attached:Class 1B Boarding house / guest hostel:Class 2 Residential flats/units:Class 3 Boarding house, hostel, backpackers or residential part of hotel, motel school:Class 4 Caretakers/Managers flat:Class 5 Office building:Class 6 Shop:Class 7a Carpark or 7b Warehouse:Class 8 Factory/Workshop/Laboratory:Class 9a Healthcare 9b Assembly 9c Aged Care Building:Class 10A Non - habitable building - shed, garage, carport:Class 10B Structure - mast, antenna, ret wall, swim pool:Other: ___________________________________________FloorArea]:m 2What is the proposed value of buildingwork? (total contract price inc GST):$6. OWNER DETAILSOwner Name 1:Owner Name 2:Signature:Date:Response Time: 3 Working Days from date of receipt