Application for Certificate of Approval of Public Building (Form 2)
Health Act (Miscellaneous Provisions) 1911
Health (Public Buildings) Regulations 1992
(Reg.5)
Team Name
Premises Details
Name of Public Building
*
Address of Premises
*
Nearest cross street
Construction / extension / alteration of which was completed on
*
-
Day
-
Month
Year
Date
In accordance with your approval given on
*
-
Day
-
Month
Year
Date
Applicant Details
Name of Owner/Agent
*
Address
*
Suburb
*
Phone
Mobile
Format: 0000 000 000.
Email
example@example.com
Owner / Agent Signature
*
Date
*
/
Day
/
Month
Year
Submit
Should be Empty: