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Building Permit Application
Legal Description:
House Number:
(If assigned)
Road Name:
OWNER INFORMATION Primary Contact
Name(s):
Mailing Address:
City/Prov:
Postal Code:
email:
Tel:
Cell:
AGENT INFORMATION Primary Contact
Name(s):
Mailing Address:
City/Prov:
Postal Code:
email:
Tel:
Cell:
CONTRACTOR INFORMATION Primary Contact
Name(s):
Plumber
T.Q. #:
Company Name:
Mailing Address:
City/Prov:
Postal Code:
email:
Tel:
Cell:
DOCUMENTS SUPPLIED WITH APPLICATION (Click Building Permit Application Requirements for more information)
Appointment of Agent form **Must be signed by all owners on title**
N/A
Residential builder “BC Housing Registration Form” or Owner Builder “New Home Registration Form” (for new dwellings)
N/A
Preliminary Planning Review ([email protected])or RDN Islands Trust Review Declaration for Gabriola(see RDN website)
YES
Required
Property Declaration Form
Required
Improvement District Water Service Area Declaration
N/A
Site Plan (Show location of proposed structure distanced to lot lines, existing buildings, setbacks, driveway, watercourses)
YES
Required
Construction plans/drawings (including engineered drawings, if applicable)
NO
BC Building Code Letters of Assurance from registered professionals (Schedules A and/or B)
NO
Proof of liability insurance from Professional Engineer(s)
NO
Hazardous Materials Declaration Form required for demolitions, additions, alterations, repairs, and moved-on buildings
NO
Truss layout
NO
Septic Filing or Registered Onsite Wastewater Practitioner’s (ROWP) report
NO
Pre-construction BC Energy Compliance report - Performance paths for Part 9 Buildings
NO
Alternate Solution
N/A
Manufacturer’s specification sheet (for mobile or modular homes)
N/A
Mobile or modular home certification standard and number:
CSA - Z240
CSA - A277
CSA No:
PROPOSED CONSTRUCTION
Detailed scope
of work:
Value of construction
$
Building Area:
Number of stories:
Number of bedrooms:
New
Dwelling
Commercial
Addition
Secondary Suite
Industrial
Renovation
Accessory Dwelling
Institutional
Demolition
Manufactured Home
Multi-Residential
Moved on Building
Accessory Building
Other
Plumbing
Fire Suppression System
Other
Building Inspection Services, Regional District of Nanaimo
6300 Hammond Bay Road, Nanaimo, BC V9T 6N2
250-390-6530
[email protected]
Revised July 2023
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CONSTRUCTION DETAILS (must be shown on plans)
Woodstove
Electrical fixtures
Slab
Heating System:
Factory fireplace
Plumbing fixtures
Crawl space
Electric Baseboard
Masonry fireplace
Heating Appliance
Finished Basement
Heat Pump
Gas fireplaces
Garage
Unfinished Basement
Forced Air
Gas appliances
Carport
Other
In-floor Radiant
Masonry chimney
Decks
Not applicable
None
Factory Built chimney
Verandahs
Not applicable
Retaining Walls
Not applicable
SITE INFORMATION
Has or will blasting be carried out on the subject property?
YES No
Has or will fill been placed on site?
YES No
Distance to North Lot Line (metres):
Distance to South Lot Line (metres):
Distance to East Lot Line (metres):
Distance to West Lot Line (metres):
Building Height: Building Separation:
Property Contains and/or Adjacent to:
Sea Lake/Pond
River/Stream
Ditch Cliff/Bank
None
Owner / Agent (Signature)
Print Name Date
Owner (Signature)
Print Name Date
Owner (Signature)
Print Name Date
*All owners must sign this form unless using an Agent.
Personal information collected on this form is collected for the purposes of processing this building permit application and for administration and enforcement. The
personal information is collected under the authority of the Local Government Act, the Regional District’s Building Bylaw and pursuant to section 26 of the Freedom of
Information and Protection of Privacy Act.
Acknowledgement of Responsibility and Undertakings
The undersigned being the owner/agent for the owner of the property herein described hereby makes application for a permit to undertake
the work as set forth in this application. I agree to conform to all requirements as may be specified by the Regional District of Nanaimo Building
Bylaw and any other applicable Bylaw or Regulation in force in the Regional District of Nanaimo.
Neither the issuance of the Permit nor the approval of the drawings and specifications submitted as part of this application, by the Regional
District of Nanaimo Building Inspection Department or designates thereof, shall, in any way relieve the applicant from the responsibility of
ensuring the construction for which this permit issued, is carried out in conformity with the requirements of the Building Bylaw and any other
applicable Bylaws and Regulations, nor prevent the Building Inspector, or his designate from requiring correction of any errors in construction
or violation of the Building Bylaw or other applicable Bylaw or Regulations.
The issuance of a building or occupancy permit is not a warranty that the building complies in every respect with the Building Code or meets
any particular standard of construction, and that the owner is responsible for ensuring that the building for which application is made complies
with the Building Code and other applicable enactments.
The undersigned owner(s)/authorized agent of the owner makes an application as specified herein and declares that the information
submitted in support of the application is true and correct in all respects.