1 March 2006, Version 2

Plumbing and Drainage Act 2002 (s. 21 SPDR)

Verification
of Covered Work 3
1. Prior approvals for the work Compliance Permit No. (If Applicable)

2. 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 (eg. SP / RP) are Postcode
shown on title documents or a rates notice.
Lot & plan details (Attach list if necessary)
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

3. Stage of Work Stage of the work covered and subject of the inspection request (tick one only)-
For plumbing and sanitary drainage laid under a floor slab or in another area where pipes or fittings
will be covered

For plumbing and sanitary drainage laid below ground level and external to a building or other
structure before backfilling

For plumbing installed in a building or other structure before cladding

For a trench or sub-surface irrigation for on-site sewerage work – before filling
with backfill or after substantially filling with backfill but leaving a cross sectional
area not backfilled

For on-site sewerage work after all pipes are connected, and effluent resulting
from sewage generated on the premises can be treated by the on-site
sewage treatment plant

Other (provide details)

4. Inspection Arrangements When was the request for the inspection made?
Date Time
If there was an agreed time for the inspection, provide details below
Date Time
When was the work covered?
Date Time

OFFICE USE ONLY

DATE RECEIVING REFERENCE
RECEIVED OFFICER’S NAME/S NUMBER/S
5. Declaration I hereby state that the work has been completed in conformity with the Standard Plumbing and Drainage Regulation 2003
Full details and signature of the and that the information provided in this form is a true and accurate record.
responsible person will need to
Name
be provided to verify that the
work covered complies with the
Plumbing and Drainage Act
2002 and Standard Plumbing Plumber’s Licence No. Drainer’s Licence No.
and Drainage Regulation 2003.

Other Licence/Registration No.

Phone No. Mobile No. Fax No.

Address

Postcode
Signature Date