DEMOLITION LICENCE - APPLICATION - DEMOLITION - 01 MAY 2021 - Service NSW
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Work Health and Safety Act 2011 (WHS Act) –
Work Health and Safety Regulation 2017 (WHS Regulation)
DEMOLITION LICENCE – APPLICATION
DEMOLITION – 01 MAY 2021
Complete this form to apply for a new licence for Privacy compliance statement
demolition work under the WHS Regulation 2017. Information that you voluntarily provide in this
Complete the Demolition supervisor nomination form is collected by SafeWork NSW to assess and
– application (Demolition – 03) (catalogue no. process your application.
SW08100) to add additional supervisors to your SafeWork NSW intends to use and disclose the
licence application. information (including any personal information)
How to fill in this form you have provided in the following ways:
Refer to the Guide for applicants for demolition 1. to exercise its functions under the Work Health
licences and notifications (catalogue no. and Safety Act 2011, including to administer,
SW08018) when completing this application. monitor and enforce compliance with that Act
Please type directly into the form. When complete, 2. to record your information on a licence register,
save a copy before emailing or printing. parts of which will be published online
If completing by hand, please print clearly and 3. to disclose your information to other state,
mark box(es) with a tick where required. territory and the Commonwealth regulatory
For assistance call 13 10 50 authorities
4. to educate about work health and safety and
Fees
contribute to external research about work
Refer to the SafeWork NSW fee schedule available health and safety
at www.safework.nsw.gov.au or call 13 10 50.
5. as otherwise required or permitted by law,
Lodgement instructions including for prosecution.
Email: licensing@safework.nsw.gov.au SafeWork NSW has a Privacy Management Plan
Identity documents which provides more detailed information about
Applicant will need to provide 1 photo who SafeWork NSW is, how to contact SafeWork
identification and 1 secondary identification NSW, and how SafeWork NSW manages personal
document and will need to complete facial and health information in line with NSW privacy
verification at a Service NSW Centre. laws. A copy of the Privacy Management Plan is
Photo identification available at www.safework.nsw.gov.au.
• Current Australian Driver’s licence / permit The Privacy Management Plan provides detailed
information about how you may access or
• Passport – Australian or international (current
amend personal information held about you by
or expired within the last two years but not
SafeWork NSW.
cancelled)
• Photo Australian citizenship card
Secondary identification documents
• Birth certificate, citizenship certificate or
passport (passport must be current or expired
within the last two years, but not cancelled).
• Current Medicare card
• Property lease agreement
• Home insurance papers
• Utility bills issued in the last three (3) months
• Current motor vehicle registration
• Motor vehicle insurance papers
• Telephone account issued in the last
three (3) months.
1/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 1. tYPe oF DemoLItIon
Indicate the demolition licence for which you are seeking a licence. Mark one box only.
Restricted demolition Demolition
SectIon 1.1 aUtHoRISatIonS ReQUIReD FoR an UPGRaDe oF a ReStRIcteD DemoLItIon LIcence
Mark the appropriate boxes.
Demolition of chemical installations Demolition of pre-tensioned or post-tensioned structures
Demolition using a tower crane on site Demolition above 15 metres in height
Demolition using explosives Demolition involving floor propping
Demolition using a mobile crane with a rated capacity of more than 100 tonnes
SectIon 2. aPPLIcant’S DetaILS
Mark one box only.
Individual Corporation
SectIon 2.1 coRPoRatIon aPPLIcant DetaILS
Registered name ABN
ACN
Registered business (trading) name (if applicable)
* The ABN or ACN must be attached to the legal
name entered above
STREET ADDRESS (MUST NOT BE A PO BOX) POSTAL ADDRESS Same as street address
Unit number/Street number/Property number Unit number/Street number/Property number
(include Lot or DP number if applicable) (include Lot or DP/PO Box/GPO Box/Private Bag/Locked Bag)
Street name Street name
Suburb Suburb
State Postcode State Postcode
Ensure all fields are filled out accurately with current information pertaining to the business and
nominated contact person.
2/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 2.2 InDIVIDUaL aPPLIcant DetaILS oR contact PeRSon FoR coRPoRatIon aPPLIcatIonS
Family/Surname Daytime contact number Mobile number
Given name Email
Other names Registered business (trading) name (if applicable)
Date of birth (DD/MM/YYYY)
ABN
SectIon 3. InSURance
If you are an employer and not exempt under the Workers Compensation Act 1987 (WC Act) from
holding a workers compensation insurance policy, you must supply a certificate of currency for workers
compensation insurance with this application. Refer to the Guide for applicants for demolition licences
and notifications (catalogue no. SW08018). You must also provide a certificate of currency for public
liability insurance with ‘demolition’ listed as the business activity.
WORKERS COMPENSATION INSURANCE
I am an exempt employer under the Workers Compensation Act 1987 OR
I have attached a copy of the certificate of currency for workers compensation.
PUBLIC LIABILITY INSURANCE
I have attached a copy of the public liability insurance certificate of currency with ‘demolition’ listed as
the business activity.
SectIon 4. nomInateD SUPeRVISoR’S DetaILS
Corporation applicants must nominate a person who is involved in the management of the corporation
and who is qualified in the demolition work for which the licence is sought. This person is referred to as
the management supervisor. Mark one box only.
I am an individual applicant.
I am involved in the management of the corporation. Please complete the following details:
Family/Surname Date of birth (DD/MM/YYYY)
Given name Daytime contact number Mobile number
Other names Email
SectIon 4.1 SUPeRVISoR’S DecLaRatIon (if supervisor is not the applicant)
I acknowledge and agree to be nominated as the management supervisor in this application OR with the
change in details as provided in this application OR to the removal of my name against the licence as
outlined in this application OR to be nominated as a supervisor for the additional demolition work outlined
in this application (delete whichever is not applicable).
Supervisor’s signature Date (DD/MM/YYYY)
The supervisor is no longer in my (licence holder’s) employment. This declaration does not require
completion.
3/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 4.2 PoSItIon In tHe coRPoRatIon
Is the nominated supervisor a director or general manager (or equivalent) of the corporation?
Yes.
No. I have attached a letter from the director of the corporation, stating the supervisors role in the
management of the corporation and authorising them to act as the management supervisor for
the purpose of this licence.
SectIon 4.3 BUSIneSS aDDReSS (oF tHe manaGement SUPeRVISoR)
Same as the corporation’s address.
Unit number/Street number/Property number
(include Lot or DP number if applicable) Suburb
Street name State Postcode
SectIon 4.4 aDDItIonaL SUPeRVISoR(S)
You must complete and attach the Demolition supervisor nomination – application (Demolition – 03)
(catalogue no. SW08100) for each additional supervisor that you wish to nominate.
I am nominating additional supervisor(s):
Yes, I have attached (insert the number) demolition supervisor nomination forms.
No
SectIon 5. QUaLIFIcatIonS (OF PRE APPROVED INDIVIDUAL APPLICANT OR
THE MANAGEMENT SUPERVISOR)
Refer to the Guide for applicants for demolition licences and notifications (catalogue no. SW08018) for
more details about the knowledge and experience required.
Have you previously been authorised to supervise demolition work on another NSW issued licence?
Yes. Please indicate the type(s) of demolition work and the licence holder name and/or the licence
number for whom you supervised work.
No. Please go to section 6.
DEMOLITION
Restricted demolition work
Licence number Licence holder name
Demolition work
Licence number Licence holder name
DEMOLITION TYPES
Demolition of chemical installations
Licence number Licence holder name
4/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
Demolition of structures above 15 metres
Licence number Licence holder name
Demolition using a tower crane
Licence number Licence holder name
Demolition of pre or post tensioned structures
Licence number Licence holder name
Demolition involving floor propping
Licence number Licence holder name
Demolition using a mobile crane rated capacity more than 100 tonne
Licence number Licence holder name
Demolition using explosives
Licence number Licence holder name
5/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 6. eVIDence oF IDentItY DecLaRatIon
Individual applicants and Directors of Corporations will need to provide copies of relevant training qualifications
and attend Service NSW office to complete facial verification and attach copies of 2 identity documents.
Photo identification Document
Only use one document Current Australian Driver’s licence / permit
Passport – Australian or international (current or expired within the last two years but
not cancelled)
Photo Australian citizenship card
Secondary documents Document
1. Allowed to use a Australian Birth Certificate / card issued by the Registrar of Births, Deaths and Marriages
combination of
secondary documents Student card issued by a tertiary institution
2. Documents provided Utility bill in applicant’s name (e.g. council rates notice, water, power or phone account)
must contain the
Medicare card
participants full name
(not initials) Credit or debit card, passbook or account statement from a financial institution (only
one per financial institution can be counted)
SeRVIce nSW USe onLY
Document type Date of issue State of issue Documentation number Expiry date
Name of Service NSW Checking Officer Service NSW disclaimer
• Service NSW is acting as an agent for the SafeWork
NSW to identify you under the requirements set out
Location of Service NSW centre by the NSW Explosives Act.
• Your application will be forwarded to SafeWork NSW
who will determine whether a licence will be granted.
Signature Date (DD/MM/YYYY) • SafeWork NSW is required, under the NSW
Explosives Act, to provide licensees with certain
information. This information will be sent to you when
and if your application is approved.
Notes
SectIon 7. eVIDence oF eXPeRIence anD tRaInInG / QUaLIFIcatIonS
Applicant’s trading under a business name who will be nominating supervisor(s) to carry work out on
behalf of the licence holder, will not be required to meet the training or experience requirements.
All individual applicants will be required to meet the training and experience requirements.
All nominated Supervisors will be required to meet the training and experience requirements.
Evidence of experience must be completed as outlined in the experience table and attached to the
application form that outlines work undertaken. Evidence must include a detailed description of work
experience for at least three (3) demolition jobs within the last five years. Supporting documents may
include, but is not limited to, contracts demonstrating the engagement demolition work, work diaries or
logbooks for the work undertaken. This must include dates and locations of jobs, quantities removed, and
a description of each job. Reference letters must be provided from employers or organisation on company
letter head, dated and signed with referees that can be contacted to verify the work undertaken. Refer to the
Guide for Applicants for Demolition licences and notifications (catalogue no. SW08018) for more information
6/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
RESTRICTED
nominated
Date Project name/location Demolition work completed Supporting documents
supervisor
• Date work Demolition project name, Experience must involve Provide • Site Induction register
completed site details/ location/ undertaking work in one or a details of the • Demolition Work Plan
• Duration quantities removed combination of trades, where nominated • Asbestos clearance
of job Minimum of 3 examples demolition work was undertaken. supervisor that certificate (if applicable)
over a 3 year period. Minimum 3 jobs over a 3 year period. supervised this • Traffic Management Plan
• Demolition work (include • SWMS – copy of the one used
• Carpentry contact details) on the site with signatures
• Building • Risk register
• General Construction • Plant service report for
• Civil Construction all plant used during the
• Excavation demolition
• Other • Reference letter
UNRESTRICTED
nominated
Date Project name/location Demolition work completed Supporting documents
supervisor
• Date work Demolition project name, Experience must include being Where • Site Induction register
completed site details/ location/ involved in the undertaking of all applicable • Demolition Work Plan
• Duration quantities removed the below demoliton types. Note: provide • Asbestos clearance
of job Minimum of 3 examples A restricted demolition licence can details of the certificate (if applicable)
over a 3 year period. be granted with one or more of nominated • Dilapidation report
the below restrictions lifted if not supervisor that • Traffic Management Plan
involved in all the demolition types. supervised this • Engineers report /
Minimum 3 jobs over a 3 year period. work (include investigation
• Demoliton of a structure or plant contact details)
• SWMS – copy of the one
over 15 metres in height used on the site with
• Demolition that involved a signatures
chemical installation • Risk register
• Demolition that involve a tower • Plant service report for
crane/s all plant used during the
• Demolition that involved a mobile demolition
crane with a rated capacity of
more than 100 tonnes
• Demolition of structural
components that were pre-
tensioned or post-tensioned
• Demolition that involved floor
propping
• Demolition that involved
explosives
• Other
7/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
I have attached written reference(s) to support the experience detailed above
I have attached two safe work method statements, required for each demolition type nominated above
I have attached photographs of the work undertaken, required for each demolition type nominated above
I, the undersigned, do solemnly and sincerely declare that the information contained on this form is true
and correct in every particular, to the best of my knowledge.
Individual applicant/management supervisor’s signature Date (DD/MM/YYYY)
Attach copy of the certification issued to applicant for the specified VET course:
CPCCDE4001A - Plan and prepare for activities on demolition sites
CPCCBC4012B - Read and interpret plans and specifications
CPCCDE3018A - Select and use small plant and equipment for demolition tasks. This unit has a
prerequisite unit
CPCCOHS2001A - Apply OHS requirements, policies and procedures in the construction industry
CPCCDE3019A - Demolish small buildings and structure using hand tools and small plant equipment
CPCCDE3016A - Identify hazards on demolition sites and apply risk management strategies
CPCCDE3020A - Select and use tools and equipment for hot work in the demolition industry
CPCCDE3022A - Manage demolition recyclable and waste materials using load shifting equipment
CPCCDE4003A - Supervise individual activities on demolition sites
CPCCDE4002A - Plan and supervise demolition work to minimise environmental and public health and
safety impact
CPCCBC4002A - Manage occupational health and safety in the building and construction workplace
CPCCDE4004A - Finalise demolition activities and supervise property handover
I have attached a copy of my certificate or transcript or statement of attainment
GENERAL CONSTRUCTION INDUCTION TRAINING
It is a requirement of the WHS Regulation that workers carrying on construction work must have a General
Construction Induction Training (GIT) card, or training certification pending the issue of a GIT card.
GIT card number for the nominated supervisor
If a GIT course was completed within the last 60 days, provide the Statement of Training number issued
by the registered training organisation
If issued outside NSW, provide the state or territory where issued (a copy of the front and back of the
interstate card must also be attached)
8/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
CONSENT TO VALIDATE QUALIFICATION CERTIFICATES
Declaration
I, (print name)
hereby authorise (insert name(s) of educational provider who issued your training certificate)
To provide SafeWork NSW with any educational training records that relate to my application for a
demolition licence.
Signature Date (DD/MM/YYYY)
PRIVACY STATEMENT
This information is collected by SafeWork NSW for the purpose of verifying the training documents
supporting this application for a demolition licence. The information will not be accessed by any third
parties in a way that would identify you, unless the disclosure is required by law.
Please go to section 9.
SectIon 8. DIScLoSURe StatementS
For legal purposes, the term ‘you’ on this page means:
• the licence applicant
• (in the case of a corporation applicant) the corporation itself and each officer of the corporation.
Have you ever been convicted or found guilty of an offence under workplace health and safety (WHS) laws
in Australia?
Yes. If yes provide details. No
Have you ever provided a statement or information to SafeWork NSW knowing that the information was
false or misleading?
Yes. If yes provide details. No
Have you ever failed to comply with the conditions of a conditional asbestos or demolition licence?
Yes. If yes provide details. No
Have you been issued a significant number of notices for unsafe systems of work?
Yes. If yes provide details. No
Have you ever had an asbestos or demolition licence cancelled or suspended by SafeWork NSW?
Yes. If yes provide details. No
9/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 9. manaGement SUPeRVISoR’S DecLaRatIon
I acknowledge and agree to be nominated as the management supervisor in this application.
The information provided in this application is true and correct.
Management supervisor’s signature Date (DD/MM/YYYY)
SectIon 10. aPPLIcant’S DecLaRatIon
I, (print name)
hereby declare:
• the information supplied in this application is true and correct to the best of my knowledge
• I consent to SafeWork NSW making enquiries and exchanging information with work health and safety
regulators in other states, territories, or the Commonwealth regarding any matter relevant to this
application
• I consent to SafeWork NSW making enquiries and validating my qualifications with the educational
provider who issued my qualification certificates
• I consent to SafeWork NSW contacting my referees to verify my evidence of experience
• the applicant does not hold an equivalent licence granted by a corresponding regulator under a
corresponding work health and safety law.
• I have read the privacy compliance statement and consent to SafeWork NSW using my information
(including personal information) as outlined in the statement.
SafeWork NSW compiles a public register of asbestos removal licence holders on the SafeWork NSW website.
Please mark the proposed region(s) you will operate in, as per the SafeWork NSW region map key below.
A B C D E F G H I J K L M or ALL
Tweed Heads
Casino Lismore
Moree H F
Bourke Walgett Inverell
Grafton
Glen Innes
J I Narrabri
Coonamble Armidale
Tamworth
Cobar Nyngan Coonabarabran
G Kempsey
Wilcannia
Gilgandra Port Macquarie
Broken Hill Taree
Dubbo C
Maitland B Newcastle
Orange Toronto
K L Parkes Gosford
Bathurst
Wentworth Griffith Lithgow
A Sydney
Hay E Wollongong
Narrandera Yass Goulburn
Wagga D
Deniliquin Wagga
Finley Albury Canberra
Cooma
M
Bega
Applicant’s signature Date (DD/MM/YYYY)
Note: It is an offence to make a false or misleading statement in applications under clause 268 of the WHS Act.
The maximum penalty is $10,000.
Note: A Director must sign on behalf of a Corporation.
10/11DemoLItIon LIcence – aPPLIcatIon DemoLItIon – 01 maY 2021
SectIon 11. LoDGement FeeS
A fee must be paid on lodgement of the application form.
Refer to the SafeWork NSW fees schedule available at www.safework.nsw.gov.au.
Pay by credit card or PayPal using the following link:
www.safework.nsw.gov.au/applicationpayments
STEP 1 – Click on the link or type the URL into your web browser
STEP 2 – Follow the instructions online to complete payment
STEP 3 – When the lodgement fee is paid online you will receive a receipt number. Please record the
receipt number below before lodging the application; not providing this information may result in delays in
processing your application.
Receipt number
Note: If you are having difficulty lodging this payment online, please contact SafeWork NSW on 13 10 50.
SectIon 12. cHecKLISt to SUBmIt YoUR aPPLIcatIon
Attached Document
Copy of certificate of currency of workers compensation insurance. Applicants who are
not exempt employers (please refer to the Guide for applicants for demolition licences and
notifications (catalogue no. SW08018)) must attach a legible copy of the certificate of currency
for workers compensation insurance to this application.
Copy of certificate of currency for public liability insurance stating business activity as ‘demolition’.
If the supervisor is not a director or general manager (or equivalent) of the corporation, a
letter from the director of the corporation, stating the supervisors role in the management of
the corporation and authorising them to act as the management supervisor for the purpose of
this licence.
Copy of the certificate or transcript or statement of attainment showing successful completion
of SafeWork NSW recognised training course. (Only required if seeking authorisation for the
first time).
Copy of General Induction Training card (front and back) if issued outside NSW.
Written references that support the description of the work undertaken. (Only required if
seeking authorisation for the first time).
Two safe work method statements. Required for upgraded restricted demolition and for
demolition licence work for each demolition type outlined in section 2.1.
Photographs of work undertaken. Required for upgraded restricted demolition and demolition
licence work, for each demolition type outlined in section 2.1.
To add additional supervisor(s) to a licence complete and submit the Demolition supervisor
nomination – application (Demolition – 03) (catalogue no. SW08100) for each supervisor.
Catalogue No. SW08099 | © Copyright SafeWork NSW 0521 | Customer Experience 13 10 50 | Website www.safework.nsw.gov.au
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