Section 108(3)(c), Building Act 2004
Street address of building:
Legal description of land where building is located:
Building name:
Location of building within site/block number:
Level/unit number:
Name of owner:
*Contact person:
Mailing address:
Street address:
†Registered office:
The inspection, maintenance, and reporting procedures of the compliance schedule have been fully complied with during the 12 months prior to the date stated below in relation to the following specified system/s:
[state specified system(s)].
Signature of licensed building practitioner:
*Delete if applicant is individual.
†Delete if inapplicable.
Schedule 2 Part 2 form 12A: inserted, on 31 March 2005, by regulation 4(5) of the Building (Forms) Amendment Regulations 2005 (SR 2005/31).