FORM	A			Page 1 of 2	
		Geotechnical Declaration and Verification 
Development Application	
Office Use Only		Regulator:  <Add in or change to appropriate name>
     	

			
To be submitted with a development application.  If this form is not submitted with the geotechnical report the report will be refused.	
This form is essential to verify that the geotechnical report has been prepared in accordance with <Regulator’s geotechnical DCP> and that the author of the geotechnical report is a geotechnical engineer or engineering geologist as defined by <Regulator’s geotechnical DCP>.  Alternatively, where a geotechnical report has been prepared for subdivision or is greater than two years old or by a professional person not recognised by  <Regulator’s geotechnical DCP> , then this form may be used as technical verification of the geotechnical report if signed by a geotechnical engineer or engineering geologist as defined by  <Regulator’s geotechnical DCP>.

Section 1	Related Application	
Reference	What is the Council development application number?	
DA Site Address	     	
DA Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author’s Company/
Organisation Name:       	Report Reference No:       	
	Author:       	Dated:            	/       	/       	               	
	
Section 3	Checklist	
Geotechnical Requirements
(Tick as appropriate, either Yes or No)	The following checklist covers the minimum requirements to be addressed in a geotechnical report.  This checklist is to accompany the report. Each item is to be cross-referenced to the section or page of the geotechnical report which addresses that item.	
Yes             No			
        	A review of readily available history of slope instability in the site or related land as per <Add reference>      
	
        	An assessment of the risk posed by all reasonably identifiable geotechnical hazards as per <Add reference>     
	
        	Plans and sections of the site and related land as per <Add reference>      
	
         	Presentation of a geological model as per <Add reference>      
	
        	Photographs and/or drawings of the site as per <Add reference>      
	
        	A conclusion as to whether the site is suitable for the development proposed to be carried out either conditionally or unconditionally as per 
<Add reference>      
	
        	If any items above are ticked No, an explanation is to be included in the report to justify why. <Add reference>     

Subject to recommendations and conditions relevant to:		
Yes             No			
        	selection and construction of footing systems,
	
        	earthworks,
	
        	surface and sub surface drainage,
	
         	recommendations for the selection of structural systems consistent with the geotechnical assessment of the risk,
	
        	any conditions that may be required for the ongoing mitigation and maintenance of the site and the proposal, from a geotechnical viewpoint,
	
        	highlighting and detailing the inspection regime to provide the <PCA> and builder with adequate notification for all necessary inspections.
	
        	State Design life adopted:       Years	
Note:  <Add reference>:  Add in the relevant section or page number of the listed geotechnical report which addresses each item.	

FORM	A		Page 2 of 2	
		Geotechnical Declaration and Verification 
Development Application		
			
Section 4	List of Drawings referenced in Geotechnical Report	
Design Documents
	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	

Section 5	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and on behalf of the company below, I:	
Yes             			
    No 	am aware that the geotechnical report I have either prepared or am technically verifying (referenced above) is to be submitted in a support of a development application for the proposed development site (referenced above) and its findings will be relied upon by <the Regulator> in determining the development application.
	
   N/A 	prepared the geotechnical report referenced above in accordance with the AGS (2007c) as amended and <Regulator’s geotechnical DCP>.
	
   N/A 	am willing to technically verify that the Geotechnical Report referenced above has been prepared in accordance with the AGS (2007c) as amended and <Regulator’s geotechnical DCP>.
	
    No  	am willing to technically verify that the geotechnical report prepared for the development application for the site confirms the land will achieve the level of <tolerable risk> of slope instability as a result of the considerations described in <add reference to specific section of> <Regulator’s geotechnical DCP> taking into account the total development and site disturbances proposed.
	
    No 	am willing to technically verify that the geotechnical report prepared for the site and related land being greater than two years old confirms the land will achieve the level of <tolerable risk> of slope instability as a result of the considerations described <add reference to specific section of> of <Regulator’s geotechnical DCP> taking into account the total development and site disturbances proposed.
	
    No 	have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.	
			
Section 6	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:         /        /       	               	
Reference: AGS (2007c) “Practice Note Guidelines for Landslide Risk Management”. Australian Geomechanics Society, Australian Geomechanics, 
V42, .N1, March 2007.
Note: N/A = Not Applicable.

FORM	B			Page 1 of 2	
		Structural/Civil/Geotechnical Engineering
Declaration – <Construction Certificate> Application	
Office Use Only		Regulator:  <Add in or change to appropriate name> 
     	

			
To be submitted with the structural design forming part of an application for a <construction certificate>.	
This form must be attached with the submission of the structural documentation required for the determination of a <construction certificate> or combined development application and <construction certificate> submission.
This form is essential, as it provides evidence to the <PCA> determining the <construction certificate>, that the structural design has been prepared or verified by a structural engineer or civil engineer as defined by <Regulator’s geotechnical DCP> and that the structural design has been prepared in accordance with the recommendations given in the geotechnical report for the same development.  This form also covers additional design documents required to cover other works not shown on the main structural/civil design drawings. This form is also essential to establish that the recommendations given in the geotechnical report have been interpreted and incorporated into the structural design as originally intended by the geotechnical engineer in preparing the geotechnical report.

Section 1	Related Application	
Reference	What is the <Regulator’s> development application number?	
DA Site Address	     	
DA Applicant	     	
			
Section 2	Structural/Civil Design Documents	
List of Structural/Civil Design Documents
(More space on page two if required)	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
		
Section 3	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:       	Report Reference No:       	
			
Section 4	Declaration by Structural/Civil Engineer or Designer of Additional Design Documents in Relation to a Geotechnical Report	
Declaration
(Tick all that apply)		
Yes             No			
        	I am a structural or civil engineer as defined by the <Regulator’s geotechnical DCP> and on behalf of the company below.
	
        	I have prepared the structural designs listed in Section 2 above and/or Section 6 below, in accordance with the recommendations given in the above geotechnical report.
	
        	I am a design engineer and have prepared Additional Design documents listed in Section 7 below in accordance with the recommendations given in the above geotechnical report.
	
        	I am aware that the <PCA> will rely on this declaration in granting a <construction certificate> for works to which the above structural design documents and geotechnical report relate.
	
        	I certify that any residential structure designed or erected in accordance with the structural design prepared by the structural engineer or civil engineer achieves the performance requirements of Clause 1.3 of the current version of AS 2870 (this must be ticked when accompanied by minimal impact certification).
	
         	I have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.	

FORM	B			Page 2 of 2	
		Structural/Civil/Geotechnical Engineering
Declaration – <Construction Certificate> Application	
			
Section 5	Structural/Civil/Design Engineer Details	
Company/ Organisation Name	
     		
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given:       		
	Chartered Professional Status:       	Registration No:       	
Signature		Dated:             /        /       	               	
		
Section 6	Ancillary Structural/Civil Design Required Prior to Completion of Geotechnical Declaration	
List of Structural Design Documents
Required
	Description	Company Responsible	Plan or Document No.	Revision or Version No.	Date of Additional Form B *	Author	
	      eg. Landscaping retaining walls	     	     	     	     	     	
	      eg. Anchor design	     	     	     	     	     	
	     	     	     	     	     	     	
		
Section 7	Additional Design Documents Required Prior to Completion of Geotechnical Declaration	
List of Design Documents
Required
	Description	Company	Plan or Document No.	Revision or Version No.	Date of Additional Form B *	Author	
	      eg. Surface & subsoil drainage design	     	     	     	     	     	
	      eg.  Infiltration or effluent disposal	     	     	     	     	     	
	     	     	     	     	     	     	
		
Section 8 and 9 are not to be completed until each relevant ancillary and additional Form B has been completed and forwarded to the geotechnical engineer/engineering geologist	
		
Section 8	Declaration in Relation to Structural/Civil Designs and Additional Design Drawings	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and on behalf of the company below:	
Yes             No			
        	I prepared and/or technically verified the above geotechnical report and now declare that I have viewed the above listed design documents prepared for the same development.
	
        	I am satisfied that the recommendations given in the above geotechnical report have been incorporated into the design documents as intended.
	
        	I consider no additional drawings are required to show all the required works listed in the Geotechnical Report.

Section 9	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:             /        /       	               	
Note: *  A separate Form B is required to be completed by the design engineer for those works listed in each of Sections 6 and 7 of this Form B.

FORM	C			Page 1 of 2	
		Geotechnical Declaration  
Subdivision <Construction Certificate> Application	
Office Use Only		Regulator:  <Add in or change to appropriate name>
     	

			
To be submitted with an application for an engineering <construction certificate> for subdivision of land.  This form must be attached to the application for the <construction certificate>.	
This form is essential to verify that the geotechnical report has been prepared in accordance with <Regulator’s geotechnical DCP> and that the author of the geotechnical report is a geotechnical engineer or engineering geologist as defined by <Regulator’s geotechnical DCP>.  Alternatively, where a geotechnical report has been prepared by a professional person not recognised by the <Regulator’s geotechnical DCP>, then this form may be used as technical verification of the geotechnical report if signed by a geotechnical engineer or engineering geologist as defined by  <Regulator’s geotechnical DCP>.

Section 1	Related Application	
Reference	What is the Regulator’s Development Application Number?	
DA Site Address	          	
DA Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:       	Report Reference No:      	
			
Section 3	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and on behalf of the company below:	
Yes             No			
        	I prepared the geotechnical report referenced above in accordance with the AGS (2007c) as amended and the <Regulator’s geotechnical DCP>.
	
        	I am willing to technically verify that the geotechnical report referenced above has been prepared in accordance with the AGS (2007c) as amended and <Regulator’s geotechnical DCP>.
	
        	I have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.
	
         	I am aware that the geotechnical report I have either prepared or am technically verifying (referenced above) is to be submitted in support of an engineering <construction certificate> for subdivision of land for the proposed development site (referenced above) and its findings will be relied upon by <the Regulator> determining the engineering <construction certificate>.

FORM	C			Page 2 of 2	
		Geotechnical Declaration  
Subdivision <Construction Certificate> Application	
	
Section 4	Checklist	
Geotechnical Requirements
(Tick as appropriate, either Yes or No)	The following checklist covers the minimum requirements to be addressed in a geotechnical report in accordance with <Add reference to specific section of> <Regulator’s geotechnical DCP>.  This checklist is to accompany the report.	
Yes             No			
        	The extent and stability of proposed embankments including those acting as retarding basins <Add reference>      
	
        	Recommended Geotechnical testing requirements <Add reference>       
	
        	Required level of geotechnical supervision for each part of the works as defined under AS3798 – Guidelines on Earthworks for Commercial and Residential Developments <Add reference>       	
         	Compaction specification for all fill within private subdivisions <Add reference>       
	
        	The level of risk to existing adjacent dwellings as a result of a construction contractor using vibratory rollers anywhere within the site the subject of these works.  In the event that vibratory rollers could affect adjacent dwellings, ‘high risk’ areas shall be identified on a plan and the engineering plans shall be amended to indicate that no vibratory roller shall be used within that zone <Add reference>       	
        	The impact of the installation of services on overall site stability and recommendations on short term drainage methods, shoring requirements and other remedial measures that may be appropriate during installation <Add reference>       	
        	The preferred treatment of any areas of unacceptable risk within privately owned allotments <Add reference>       
	
        	Requirement for subsurface drainage lines <Add reference>       
	
        	Overall suitability of the engineering plans for the proposed development <Add reference>       
	
        	Risk mitigation plan defined <Add reference>       

Section 5	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:             /        /       	               	

Reference: AGS (2007c) “Practice Note Guidelines for Landslide Risk Management”. Australian Geomechanics Society, Australian Geomechanics, 
V42, .N1, March 2007.

Note:  <Add reference>:  Add in the relevant section or page number of the listed geotechnical report which addresses each item.

FORM	D			Page 1 of 2	
		Geotechnical Declaration  
Minor Impact	
Office Use Only		Regulator:  <Add in or change to appropriate name> 
     	

			
This form may be used where minor construction works present minimal or no geotechnical impact on the site or related land.  A geotechnical engineer or engineering geologist must inspect the site and/or review the proposed development documentation to determine if the proposed development requires a geotechnical report to be prepared to accompany the development application.  Where the geotechnical engineer determines that such a report is not required then they must complete this form and attach design recommendations where required.  A copy of this form with design recommendation, if required, must be submitted with the development application.
	
Note:  In all situations, this form will need to be accompanied by Form B  where the structural engineer or civil engineer certifies that any residential structure designed or erected in accordance with the plans and specifications prepared by the structural engineer or civil engineer achieve the performance requirements of Clause 1.3 of the current version of AS 2870.

Note:  The use of this form does not preclude the geotechnical consultant from requiring a Geotechnical Report.	
	
Section 1	Related Application	
Reference	What is the Council Development Application Number?	
DA Site Address	     	
DA Applicant	     	
			
Section 2	Documentation	
List of Documents Reviewed
(More space on page two if required)	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
			
Section 3	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and I have inspected the site and reviewed the proposed development at the DA Site Address described above.  As a result of my consideration of the <Regulator’s geotechnical DCP>, of my site inspection and review of the documentation listed above, I have determined and declare that, on behalf of the company below:	
   Yes                No			
  		The current load-bearing capacity of the site will not be exceeded or be adversely impacted on by the proposed development, and
	
  		The proposed works are of such a minor nature that the requirement for geotechnical advice in the form of a geotechnical report, prepared in accordance with <Regulator’s geotechnical DCP> is considered unnecessary for the adequate and safe design of the structural elements to be incorporated into the new works as there is no change to the current landslide risk on the site in accordance with AGS (2007c), and
	
  		In accordance with AS 2870 Residential Slabs and Footings, the site is to be classified as a type:  			
	
  		I have attached design recommendations to be incorporated in the structural design in accordance with this site classification.
	
  		I have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.
	
  		I am aware that this declaration shall be used by <The Regulator> as an essential component in granting development consent for a structure to be erected on the site or related land without requiring submission of a geotechnical report complying with the <Regulator’s geotechnical DCP> in support of the development application.
	
Reference: AGS (2007c) “Practice Note Guidelines for Landslide Risk Management”. Australian Geomechanics Society, Australian Geomechanics, 
V42, .N1, March 2007.

FORM	D			Page 2 of 2	
		Geotechnical Declaration  
Minor Impact	
		
Section 4	Additional Documentation	
List of Documents Reviewed
	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
		
Section 5	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:             /        /       	               	

FORM	E			Page 1 of 2	
		Geotechnical Declaration 
Remediation	
Office Use Only		Regulator:  <Add in or change to appropriate name> 
     	

			
This form must be submitted where development must be staged for geotechnical reasons and remediation of the site to a <tolerable risk> is necessary prior to any further development continuing on the site.
	
This form is essential, as it provides verification at each stage of the development, prior to the next stage commencing, that the remediation of the site to a <tolerable risk> has been carried out in accordance with the requirements of the geotechnical report and <add reference to specific section> of <Regulator’s geotechnical DCP> and that no unforeseen ground conditions have been encountered which could impact on the integrity of structures on site or related land or the landslide risk.  The geotechnical engineer or engineering geologist who prepared and/or verified the report must carry out site inspections as determined by the report to ensure that the design(s) documented on Form(s) B have been completed prior to signing this form.

Section 1	Related Application	
Reference	What is the Development Application number?	
DA Site Address	     	Development Stage (s):         	
DA Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:      	Report Reference No:      	
		
Section 3	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and, on behalf of the company below:	
Yes             No			
		I inspected and am satisfied that the foundation materials upon which the structural elements of the development have been erected, complied with the requirements and recommendations specified in the geotechnical report for Stage (s)  <add >       of the development.
	
		To the best of my knowledge, I am satisfied that Stage(s) <add>        of the development referred to above have been carried out in accordance with all the requirements and recommendations of the above geotechnical report, and conditions of development consent relating to geotechnical issues.
	
		To the best of my knowledge, I am satisfied that where changes to the development occurred during construction, those changes were carried out in accordance with all the requirements and recommendations of the above geotechnical report, conditions of development consent relating to geotechnical issues, and any site instructions or site reports  issued by me as listed below.
	
	 	I am aware that the <PCA> requires this certificate at the end of stage of the development specified in the development approval and prior to any further development continuing on the site and related land.
	
		I am willing to technically verify that the site or related land will now achieve the level of <tolerable risk> of slope instability as defined by <Regulator’s geotechnical DCP>.
	
		I have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.	

Note: <add> relevant stage numbers to be inserted.

FORM	E			Page 2 of 2	
		Geotechnical Declaration 
Remediation	
			
Section 4	List of Site Instructions and/or Site Reports Issued	
List of Documents Issued	

Description/Title	

Reference No.	

Date	

Author	Associated Design Drawings
(tick as appropriate)	
					Yes	No	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
Section 5	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:             /        /       	               	

FORM	F			Page 1 of 2	
		Geotechnical Declaration 
Final Structural/Civil Certificate	
Office Use Only		Regulator:  <Add in or change to appropriate name>
     	

			
This form must be submitted to the <PCA> at the completion of a project and prior to the issue of an <occupation certificate>.
	
This form is essential, as it provides evidence to the <PCA> that the development works have been carried out in accordance with the requirements of the structural design, any site inspections, and that any changes to the development occurring during construction, were carried out in accordance with all the requirements and recommendations of the structural design and geotechnical report, conditions of development consent relating to geotechnical issues, and any site instructions issued.

Section 1	Related Application	
Reference	What is <the Regulator’s> Development Application number?      	
DA Site Address	     	
DA Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:	Report Reference No:	
		
Section 3	Structural Civil Design Documents appropriate to the ‘as constructed’ development	
List of Structural Civil Design Documents
(More space on page two if required)	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
			
Section 4	Declaration	
Declaration
(Tick all that apply)	I am a structural or civil engineer as defined by the <Regulator’s geotechnical DCP> and I prepared the above structural designs in accordance with the recommendations given in the geotechnical report described above on behalf of the company below.  I:	
Yes             No			
        	inspected and am satisfied that the structural elements of the above development have been erected, and complied with the requirements and recommendations specified in the structural design and geotechnical report.
	
        	to the best of my knowledge, am satisfied that the above development has been carried out in accordance with all the requirements and recommendations of the structural design and above geotechnical report, and conditions of development consent relating to geotechnical issues.
	
        	to the best of my knowledge, am satisfied that where changes to the development occurred during construction, those changes were carried out in accordance with all the requirements and recommendations of the structural design and above geotechnical report, conditions of development consent relating to geotechnical issues, and any site instructions issued by me as listed below.
	
         	am aware that the <PCA> requires this certificate prior to issuing an<occupation certificate> for the above development and will rely on this certificate as verification that the above development has been erected, and complied with the requirements and recommendations specified in the structural design and geotechnical report as defined by <Regulator’s geotechnical DCP> and in determining the <occupation certificate>.
	
        	have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.	

FORM	F			Page 2 of 2	
		Geotechnical Declaration 
Final Structural/Civil Certificate		
		
Section 5	List of Site Instructions Issued	
List of Documents Issued	
Description/Title	Reference 
No.	

Date	

Author	Associated Design Drawings	
					Yes	No	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	

Section 6	Additional Design Documents	
List of Additional Design Documents	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	

Section 7	
Structural Engineer or Civil Engineer Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature

		
Dated:             /        /       		

FORM	G			Page 1 of 2	
		Geotechnical Declaration 
Final Geotechnical Certificate	
Office Use Only		Regulator:  <Add in or change to appropriate name>
     	

			
This form must be submitted to the <PCA> at the completion of a project and prior to the issue of an <occupation or subdivision certificate>.	
This form is essential, as it provides verification that the development works have been carried out in accordance with the requirements of the geotechnical report during construction, and any site inspections, and that no unforeseen ground conditions have been encountered which could have an impact on the integrity of structures on site or related land and any subsequent geotechnical requirements introduced during the construction process.

Section 1	Related Application	
Reference	What is the Development Application number?      	
DA Site Address	     	
DA Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:	Report Reference No:      	
		
Section 3	Work as Executed Drawings & Ongoing Maintenance Plans relevant to Geotechnical Risk Management	
List of Documents 
(more space on 
page 2 if required)	Description	Plan or Document No.	Revision or Version No.	Date	Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
			
Section 4	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and I prepared or verified the geotechnical report as described above on behalf of the company below.  I:	
Yes             No			
        	inspected and am satisfied that the foundation materials upon which the structural elements of the development have been erected, complied with the requirements and recommendations specified in the geotechnical report.
	
        	to the best of my knowledge, am satisfied that the development referred to above has been carried out in accordance with all the requirements and recommendations of the above geotechnical report, and conditions of development consent relating to geotechnical issues.
	
        	to the best of my knowledge, am satisfied that where changes to the development occurred during construction, those changes were carried out in accordance with all the requirements and recommendations of the above geotechnical report, conditions of development consent relating to geotechnical issues, and any site instructions or site reports issued by me as listed below.
	
         	am aware that the <PCA> requires this certificate prior to issuing an occupation or subdivision certificate for the above development and will rely on this certificate as verification that the above development has achieved the necessary level of <tolerable risk> as defined by <Regulator’s geotechnical DCP> and in determining the <occupation or subdivision certificate>.

FORM	G			Page 2 of 2	
		Geotechnical Declaration 
Final Geotechnical Certificate		
		
Section 5	List of Site Reports or Site Instructions Issued	
List of Documents Issued	

Description/Title	
Reference No.	

Date	

Author	Associated Design Drawings	
					Yes	No	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	

Section 6	
Additional Work as Executed Drawings and Ongoing Maintenance Plans relevant to Geotechnical Risk Management	
List of Additional Documents	

Description	Plan or Document No.	
Revision or Version No.	

Date	

Author	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	
	     	     	     	     	     	

Section 7	
Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature

		
Dated:             /        /       		

FORM	H			Page 1 of 2	
		Geotechnical Declaration 
<Building Certificate> or Order	
Office Use Only		Regulator:  <Add in or change to appropriate name>
     	

			
This form is to be submitted with Application for a <Building Certificate> or in response to an order.	

Section 1	Related Application	
Reference	What is the Regulator’s DA / BA / Order number?	
Site Address	     	
Applicant	     	
			
Section 2	Geotechnical Report	
Details	Title:       		
	Author:       	Dated:            	/       	/       	               	
	Author’s Company/
Organisation Name:	Report Reference No:	
		
Section 3	Declaration	
Declaration
(Tick all that apply)	I am a geotechnical engineer or engineering geologist as defined by the <Regulator’s geotechnical DCP> and I prepared or verified the geotechnical report as described above on behalf of the company below.  I:	
Yes             No			
        	have inspected the site and existing development and am satisfied that both the site and development achieves <tolerable risk> level requirement of the <Regulator’s  geotechnical DCP>.  The attached report provides details of the assessment in accordance with the <Regulator’s geotechnical DCP>.  The report also contains recommendations as to any reasonable and practical measures that can be undertaken to reduce foreseeable risk.
	
        	have inspected the site of the existing development.  The attached report details the remedial actions required to be undertaken prior to me being prepared to certify that the site and the development achieves the <tolerable risk> criteria required by the <Regulator’s geotechnical DCP>.
	
        	to the best of my knowledge, am satisfied that where changes to the development occurred during construction, those changes were carried out in accordance with all the requirements and recommendations of the above geotechnical report, conditions of development consent relating to geotechnical issues, and any site reports or site instructions issued by me as listed below.
	
         	am aware that the <PCA> requires this certificate prior to issuing a <Building Certificate> for the above development and will rely on this certificate as verification that the development has achieved the necessary level of <tolerable risk> as defined by <Regulator’s geotechnical DCP> and in determining the <occupation or subdivision certificate>.
	
        	have professional indemnity insurance in accordance with <Regulator’s geotechnical DCP> of not less than $.... million, being in force for the year in which the report is dated, with retroactive cover under this insurance policy extending back to the engineer’s first submission to <the Regulator>.	

FORM	H			Page 2 of 2	
		Geotechnical Declaration 
<Building Certificate> or Order		
		
Section 4	List of Site Reports or Site Instructions Issued	
List of Documents Issued	

Description/Title	
Reference No.	

Date	

Author	Associated Design Drawings	
					Yes	No	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
	     	     	     	     	     	     	
		
Section 5	Geotechnical Engineer or Engineering Geologist Details	
Company/ Organisation Name			
Name (Company Representative)	Surname:        	Mr /Mrs /Other:       	
	Given Names:       		
	Chartered Professional Status:       	Registration No:       	
Signature			
		Dated:             /        /