FORM 1
[Reg. 4]
HEALTH (MISCELLANEOUS PROVISIONS) ACT 1911
HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992
APPLICATION TO CONSTRUCT, EXTEND OR ALTER
A PUBLIC BUILDING
I being the owner/agent hereby apply under the Health (Miscellaneous
Provisions) Act 1911 section 176 to construct alter or extend a
public building:
PREMISES DETAILS
NAME OF
..............................................................................................................
LOCATION NO. .................... STREET
...............................................................
TOWN/SUBURB
..................................................................................................
NEAREST CROSS STREET
................................................................................
INTENTIONS FOR USE
......................................................................................
................................................................................................................................
In support of this application I hereby submit plans and detail as required
together with the prescribed fee.
ANY OF THE FOLLOWING MAY SIGN THIS NOTICE:
The owner, occupier, manager, trustee or other person by whose authority such
public building is intended to be built created or converted thereto.
SIGNED: ..................................................
OWNER/AGENT: ...................................
ADDRESS: ..............................................
TELEPHONE: .........................................
FAX: ........................................................
[Form 1 amended: Gazette
10 Jan 2017 p. 276.]
FORM 2
[Reg. 5]
HEALTH (MISCELLANEOUS PROVISIONS) ACT 1911
HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992
APPLICATION FOR CERTIFICATE OF APPROVAL
I being the owner/agent hereby apply for a certificate of approval in respect
of:
PREMISES DETAILS
NAME OF
..............................................................................................................
LOCATION NO. .................... STREET
...............................................................
TOWN/SUBURB
..................................................................................................
NEAREST CROSS STREET
................................................................................
Construction/extension/alteration of which was completed on
............................. in accordance with your approval given on
...........................................................
SIGNED: ..................................................
OWNER/AGENT: ...................................
ADDRESS: ..............................................
TELEPHONE: .........................................
FAX: ........................................................
[Form 2 amended: Gazette
10 Jan 2017 p. 276.]
FORM 3
[Reg. 9]
HEALTH (MISCELLANEOUS PROVISIONS) ACT 1911
HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992
APPLICATION FOR VARIATION OF CERTIFICATE OF APPROVAL
I being the owner/agent hereby apply for a variation of certificate of
approval in respect to:
PREMISES DETAILS
NAME OF
..............................................................................................................
LOCATION NO. .................... STREET
...............................................................
TOWN/SUBURB
..................................................................................................
NEAREST CROSS STREET
................................................................................
Reason for this variation from the existing certificate of approval is
....................
.................................................................................................................................
.................................................................................................................................
In support of the application I tender the following details as
required.................
.................................................................................................................................
.................................................................................................................................
SIGNED: ..................................................
OWNER/AGENT: ...................................
ADDRESS: ..............................................
TELEPHONE: .........................................
FAX: ........................................................
[Form 3 amended: Gazette
10 Jan 2017 p. 276.]
FORM 4
[Reg. 6]
HEALTH (MISCELLANEOUS PROVISIONS) ACT 1911
HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992
CERTIFICATE OF APPROVAL
This certificate is issued in accordance with the Health (Miscellaneous
Provisions) Act 1911 section 178(1) in respect to the public
building located at:
................................................................................................................................
known as:
................................................................................................................................
1. Purpose for which the public building is used.
2. Maximum no. of persons permitted for each
purpose.
Public Building |
Type of Use |
Maximum Accommodation |
SIGNED BY:
....................................................................
FOR THE SHIRE/TOWN/CITY OF:
.....................................................
[Form 4 amended: Gazette
10 Jan 2017 p. 276.]
FORM 5
[Reg. 10]
HEALTH (MISCELLANEOUS PROVISIONS) ACT 1911
HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992
CERTIFICATE OF ELECTRICAL COMPLIANCE
To the City/Town/Shire of:
_________________________________
___________________Date
I hereby certify that the electric light and/or
power — installation, alteration,
addition — at the undermentioned premises has been carried out
in accordance with the Health (Public Buildings) Regulations 1992.
NAME & INITIAL OF OCCUPIER __________________________________
DETAILS OF BUILDING:
Name:__________________________________________________________
No__________________ Street______________________________________
Suburb/Town _______________________________ P/Code_______________
Particulars of Installation
Describe any electrical work for which you are not responsible in these
premises.
Signature of licensed electrical contractor or electrical worker authorised to
sign on behalf of the electrical contractor/in‑house electrical
installer.
_______________________________
(Signature)
Contractor’s/in‑house electrical installer’s Business
Name:_________________
Contractor’s/in‑house electrical
installer’s Registration No:_________________
Contractor’s/in‑house electrical installer’s
Address:_______________________
Contractor’s/in‑house electrical
installer’s Telephone No:__________________
This form to be forwarded to the Local Government when work is completed.
[Form 5 amended: Gazette 3 Aug 2001
p. 3965 (disallowed: Gazette 20 Nov 2001 p. 6012);
7 Jun 2002 p. 2731; 10 Jan 2017 p. 277.]