Applicant
Name: [include preferred form of address, eg, Mr, Ms, Dr, if an individual]
†The owner of the building
†The territorial authority of the district in which the building is located
†The building consent authority responsible for consenting to the building work
†The licensed building practitioner concerned with the relevant building work
†The owner of other property (as defined in section 7 of the Building Act 2004) affected by the building work [include details of the property so affected: street address and legal description and the provision of the building code that requires the property to be protected]
†The regional authority of the region in which the dam is located
†A person who has a direct interest in the matter for determination if that matter relates to the provision of access and facilities for persons with disabilities [state the nature of the direct interest]
†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [state details of the relevant right or obligation]
†A responsible person (as defined in section 133BB of the Building Act 2004, but not including the people specified in section 177(6) of that Act)
Other parties
The other parties to this application are [state names and mailing addresses]:
†The owner of the building
†The territorial authority of the district in which the building is located
†The building consent authority responsible for consenting to the building work
†The licensed building practitioner concerned with the relevant building work
†The regional authority of the region in which the dam is located
†A person or organisation who or that has a right or obligation under any other Act to give written notice to a territorial authority about Building Act matters [give details of the relevant right or obligation]
†A responsible person (as defined in section 133BB of the Building Act 2004, but not including the people specified in section 177(6) of that Act)
Copies of this application have been sent to all the above-named parties.
The †building/†dam
Street address: [for structures that do not have a street address, state the nearest street intersection and the distance and direction from that intersection]
Legal description of land where †building/†dam is located: [state legal description as at the date of application and, if the land is proposed to be subdivided, include details of relevant lot numbers and subdivision consent]
Description of †building/†dam: [describe the building or dam, including, for example, its use, size, construction type, number of occupants]
Current state of †building/†dam: [describe the state of the building, including, for example, how it has been affected by the emergency]
Matter for determination
I apply for a determination in relation to the decision of the responsible person—
†(a)
to put in place measures to keep people at a safe distance or protect the †building/†dam under section 133BS of the Building Act 2004:
†(b)
to place a sign or notice on a †building/†dam under section 133BT of the Building Act 2004:
†(c)
to †carry out/†direct work in relation to a †building/†dam under section 133BW of the Building Act 2004:
†(d)
to direct works in relation to a †building/†dam under section 133BX of the Building Act 2004:
†(e)
not to exercise a power referred to in any of paragraphs (a) to (d).
Key details relevant to decision: [for each decision, give all details relevant to the decision (include dates and times of key events). If the responsible person gave reasons for the decision, state the reasons. If no reasons were given, state that no reasons were given.]
Reasons for application: [for each decision, set out the reasons the decision did not comply with the Building Act 2004 or was otherwise wrong]
†Related applications
The following applications have been made and are related to this application [give date of application and name of applicant]
Attachments
The following documents are attached to this application:
†(a)
a copy of the †sign/†notice/†direction/†other document that was †placed/†given/†provided by the responsible person in relation to the decision:
†(b)
[list plans, specifications, other documents, and correspondence provided in support of this application].
†I wish to give written/spoken evidence in te reo Māori.
Signed by the applicant:
‡Name and position (print):
*Delete if the applicant is an individual. |
‡Only required if applicant is not an individual and application is signed by an authorised officer or agent of the applicant. |