Download Gas Safety Certificate Template for Free

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Date%of%completion%or%connection!
(if!different!from!date!of!issuing!GSC ):! !
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GASFITTING%CERTIFICATE%OF%COMPLIANCE%%%%GAS%SAFETY%CERTIFICATE%
Client%Name:%
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%Reference%/%Job%#:%
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ICP%(if%known):!
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Address%of%work:!!
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Suburb:!!
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Town%/%City:!
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Description%of%gasfitting%work:!(If!different!gasfitting!work!wa s!do ne !by !diffe ren t!peo p le,!state!w h o!d id!w ha t!gasfittin g.)!
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Gas%supply%pressure!
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kPa!
%Risk%classification!(tick!one)! ! Low-Risk! ! General! ! High-risk!
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Gas%type%(tick!one)! ! Natural!gas!! ! LPG!! ! Biogas!! ! Other!(specify)!
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The%work%has%been%done%in%accordance%with%a%certified%design:%% !!Yes! !!No%
If!yes!–!identify!the!ce rtifie d !d esig n !inc lu din g !na m e ,!da te !an d !ve rsion.!Als o!a tta ch !a !copy!of!the!certified!design!to !this!certifica te.!
(Or!provide!reference!to!readily!acces sible !electronic!format,!eg!Internet!link.)%
Identify:%
Link:%
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The%work%relies%on%manufacturer’s%instructions:% ! No! ! Yes:%
If!yes!–!identify!the!in stru c tio n!manual!including!name ,!da te!a n d !vers ion.!Also!attach!a!copy!of!manufacturer’s!instructions!to!this!certificate.!
(Or!provide!reference!to!readily!accessible!electronic!form at,!eg!Internet!link.)!
Identify:%
Link:%
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The%work%has%been%done%in%accordance%with%means%of%compliance%(specify):!
!!Yes!–!AS/NZS!5601.1!sections!3!to!6! !!Yes!–!AS/NZS!5601.2!sections!3!to!9!!! !!No!
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Were%any%other%standards%or%gas%code%of%practice%required%for%compliance?!
!!Yes!(specify)!
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! !!No!
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Parts%of%the%gas%installation%to%which%this%certificate%relates%th at%are %safe%to%co nn ec t%to%a%gas%su pp ly? !
!!All!
!!Parts!(specify)!
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Date(s)%on%which%the%work%was%done:%
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Name%and%registration%number%of%anyone%%
who%carried%out%work%under%supervision:%
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By%signing%this%document%I%confirm%that%I%am%satisfied %that%the %wo rk %desc ribed %in%this%certificate %of%co m plianc e%
has%been%done%lawfully%an d %sa f e ly ,%a n d %th a t %th e %in f o rmation%on %t h is%c e r tif ic at e %is %c o rr e c t. %%
Certifier%name:!
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Registration%%
number:!
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Certifier%%
Signature:!
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%%%%Date:!
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Gas%Safety%Certificate:%
By%signing%this%document%I%confirm%that%the %work%des c rib e d %in %th is %G as%Safety%Certificate,%and%the%
installatio n %o r %p a rt %in st a llat io n ,%is%c o n n e c te d %t o %a %g a s%s u p p ly%a n d %is %s af e %to %u s e .% %
Name%of%person%authorised%to%certify%the%
connection:!
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Registration%number:!
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Certifier%%Signature:!
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Date:!
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This!Gas!Safety!Certificate!confirms!that!the!gasfitting!work!complies!with!the!building!code!for!the!purposes!of!Section!19(1)(e)!of!the!Building!Act!2004.!
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Certificate%of%Compliance:%
Gas Safety Certificate Template
source: energysafety.govt.nz
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