Western Australian Consolidated Regulations

HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992 - SCHEDULE 2

FORM 1

[Reg. 4]

HEALTH ACT 1911

HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992

APPLICATION TO CONSTRUCT, EXTEND OR ALTER
A PUBLIC BUILDING

I being the owner/agent hereby apply under section 176 of the Health Act 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 2

[Reg. 5]

HEALTH 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 3

[Reg. 9]

HEALTH 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 4

[Reg. 6]

HEALTH ACT 1911

HEALTH (PUBLIC BUILDINGS) REGULATIONS 1992

CERTIFICATE OF APPROVAL

This certificate is issued in accordance with section 178(1) of the Health Act 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 Area

Type of Use

Maximum Accommodation

SIGNED BY: ....................................................................

FOR THE SHIRE/TOWN/CITY OF: .....................................................

FORM 5

[Reg. 10]

HEALTH 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 in Gazette 3 Aug 2001 p. 3965 (disallowed in Gazette 20 Nov 2001 p. 6012); 7 Jun 2002 p. 2731.]