GOROMONZI RURAL DISTRICT COUNCIL

STRUCTURAL CERTIFICATE TO BE SUBMITTED IN DUBLICATE

1. STAND NUMBER………………………………………… DESIGNER’ REF:………………………………

DESCRIPTION OF PREMISES:…………………………………………………………………………………

ARCHITECT’S NAME:………………………………………………………………………………………….

OWNNER’S NAME & ADDRESS:……………………………………………………………………………..

SIGNATURE OF OWNER OR OWNER’S AGENT:……………………………………………………………

2. STRUCTURAL DRAWINGS
All structural drawings are submitted herewith and are listed hereunder:-

3. STRUCTURAL DESIGN CALCULATIONS ( CHAPTER 3 MODEL BUILDING BY-LAWS , 1977)

4. I, the undersigned , having checked the structural calculations , structural drawings and structural
specifications prepared by myself/ my firm* , do hereby accept responsibility on behalf of myself / my firm*
for these

I, my firm * further accept that Goromonzi Rural District Council is divested of liability should any action
arise from my / my firm’s* work.

FULL NAME OF REGISTERED ENGINEER: - SIGNATURE:-

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All work appertaining to this project will be inspected by:-

FULL NAME:………………………………… SIGNATURE:-…………………...................

If this certificate is signed on behalf of the firm, the following information must be signed by a Principal of the
firm.

FULL NAME:…………………………………… .SIGNATURE:……………..................................

NAME OF FIRM AND ADDRESS:…………………………………………………………………………….

…………………………………………………………………………………………………………………….

DATE:………………PLAN No. ………………..DATE RECEIVED……………

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