Form 14 - Application For Determination - Invercagill City Council
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1
2
3FORM 14
APPLICATION FOR
DETERMINATION
Section 178, Building Act 2004
Office Use:
Received by: __________ Date Received: __________
File Number: _______________
Appointment of Agent
The Applicant
Fill in this section if you want someone else to represent you
Applicants Name:
__________________________
I / we appoint:
Please circle:
Mr
Miss
Mrs
Ms
Dr
Agents Name:
______________________________
Mailing Address:
__________________________
__________________________
Please circle:
Mr
Miss
Mrs
Ms
Dr
__________________________
Mailing Address:
______________________________
*Contact Person:
__________________________
______________________________
Landline:
__________________________
______________________________
Daytime:
__________________________
______________________________
After Hours:
__________________________
To act as my/our agent in this
Mobile:
__________________________
determination.
Fax:
__________________________
Email:
__________________________
The Applicant is:
□
□
The territorial authority of the district in which the
The owner of the building
building is located
□
□
The building consent authority responsible for
The licensed building practitioner concerned with
consenting the building work
the relevant building work
□
□
The owner of other property (as defined in
A person who has a direct interest in the matter for
section 7 of the Building Act 2004) affected by the
determination if the matter for determination relates to
building work
the provision of access & facilities for persons with
include details of the property so affected: street
disabilities
______________
address & legal description and the provision of the building code
state the nature of the direct interest
________________
______________________________________________
that requires the building to be protected
__________________________________________
______________________________________________
__________________________________________
______________________________________________
__________________________________________
______________________________________________
□
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
___________________________________________________________________________________________
□
The regional authority of the region in which the dam is located.
Other Parties to this application are:
Please state names & mailing addresses
□
□
The territorial authority of the district in which the
The owner of the building
building is located
Name: ____________________________________
Name: ________________________________________
Address: __________________________________
Address: ______________________________________
□
□
The building consent authority responsible for
The licensed building practitioner concerned with
consenting the building work
the relevant building work
Name: ____________________________________
Name: ________________________________________
Version 27/06/2014 – V1
FORM14
Page 1 of 3
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