1 November 2003, Version 1

Plumbing and Drainage Act 2002 (s. 87)

Notifiable Minor Work

1. Description of land Street address (Include no., street, suburb/locality & postcode)
The description must identify all land
the subject of the application.
The lot & plan details Postcode
(eg. SP / RP) are shown on title
documents or a rates notice. Lot & plan details (If known)
If the plan is not registered by title,
provide previous lot and plan details.
Shop / tenancy no. (If applicable) Storey / level (If applicable) Local Government Area

2. Description of the work performed Provide a brief description of the work performed OR attach plan

3. Completion Date the work was completed

4. Declaration I hereby state that the work has been completed in conformity with the Standard Plumbing and
Full details and signature of the Drainage Regulation 2003 and that the information provided in this form is a true and accurate record:
responsible person will need to be
provided to verify that the work covered Name
complies with the Plumbing and Drainage
Act 2002 and Standard Plumbing and
Drainage Regulation 2003. Plumber’s Licence Number Drainer’s Licence Number

Phone Number Mobile Number Fax Number

Address

Postcode
Signature Date

OFFICE USE ONLY

DATE RECEIVING REFERENCE
RECEIVED OFFICER’S NAME/S NUMBER/S