Fillable Application for Acceptance as an Independent Qualified Person (Timaru District Council New Zealand)

Fill Online, Printable, Fillable, Blank Application for Acceptance as an Independent Qualified Person (Timaru District Council New Zealand) Form

Use Fill to complete blank online TIMARU DISTRICT COUNCIL NEW ZEALAND pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application for Acceptance as an Independent Qualified Person (Timaru District Council New Zealand)

On average this form takes 49 minutes to complete

The Application for Acceptance as an Independent Qualified Person (Timaru District Council New Zealand) form is 16 pages long and contains:

  • 3 signatures
  • 35 check-boxes
  • 168 other fields

Country of origin: NEW-ZEALAND
File type: PDF

Use our library of forms to quickly fill and sign your Timaru District Council New Zealand forms online.

BROWSE TIMARU DISTRICT COUNCIL NEW ZEALAND FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
#840894 Page | 1
Application for Acceptance as an Independent
Qualified Person
(Section 7, Building Act 2004)
PLEASE COMPLETE ALL SECTIONS
Please note: Separate documentation for each specified system applied for
South Island IQP Register IQP Secretary
C/O Building Advisory Services iqpenquiry@timdc.govt.nz
Timaru District Council Phone: 03 687 7200
PO Box 522 Fax: 03 687 7209
Timaru 7940 www.timaru.govt.nz
Ashburton District Council Mackenzie District Council
Buller District Council Marlborough District Council
Central Otago District Council Nelson City Council
Christchurch City Council Queenstown Lakes District Council
Clutha District Council Selwyn District Council
Dunedin City Council Southland District Council
Gore District Council Tasman District Council
Grey District Council Timaru District Council
Hurunui District Council Waimakariri District Council
Invercargill City Council Waimate District Council
Kaikoura District Council Waitaki District Council
Westland District Council
New application
Additional specified system to existing IQP status
IQP No:
Applicant Full Name:
Company Name:
Position Held:
Mailing Address:
(where the invoice & IQP
certificate will be sent)
Email Address:
Phone Numbers:
Fax:
#840894 Page | 2
Section A:
Please identify the systems or features for which acceptance as an Independent
Qualified Person is applied for
You may apply for more than one specified systems however the
documentation for each specified system must be standalone (i.e. Section B
through to Section D must be completed for each specified system)
SS1
Automatic systems for fire suppression
SS2
Automatic or manual emergency warning systems for fire or other dangers
SS3.1
Automatic Doors (sliding/ revolving/ panic)
SS3.2
Access Control Doors (swipe card/ key pad/ sensor/ delayed egress)
SS3.3
Interfaced Fire or Smoke Doors (electromagnetic doors holders)
SS4
Emergency lighting systems
SS5
Escape route pressurisation system
SS6
Riser main for use by fire services
SS7
Automatic back-flow preventer connected to a potable water supply
SS8
Lifts, escalators, travellators or other similar systems for moving people or
goods within buildings
SS9
Mechanical ventilation or air conditioning systems
SS10
Building maintenance units for providing access to the exterior and interior
walls of buildings
SS11
Laboratory fume cupboards
SS12
Audio Loops or other assistive listening systems
SS13.1
Smoke control systems – Mechanical Smoke Control
SS13.2
Smoke control systems – Natural Smoke Control
SS13.3
Smoke control systems – Smoke Curtains
SS14.1
Emergency power systems
SS14.2
Signs relating to, a system or feature specified in any of clauses1 to 13
SS15(a)
Systems for communicating spoken information intended to facilitate evacuation
SS15(b)
Final exits (as defined by clause A2 of the building code)
SS15(c)
Fire Separations (as defined by clause A2 of the building code)
SS15(d)
Signs for communicating information intended to facilitate evacuation
SS15(e)
Smoke Separations (as defined by clause A2 of the building code)
SS16
Cable Cars
NB: If you are applying for any specified system 1 to 13, you may apply for
SS14.2 signs – as they relate to the specified system that you are applying for.
Note: You will need to have a detailed knowledge of NZBC F8
#840894 Page | 3
Section B: Qualifications & Experience (Please refer to the First Schedule
Requirements)
Qualifications
List Current Specified Systems (if any) that you are approved for by the South
Island IQP Register and the status of those systems e.g. Inspection only,
Maintenance Inspection and Reporting.
Please list below the qualifications and experience you hold that is applicable to
each specified system or feature applied for. It is important to note that all
applicants are assessed as to their competence in respect of each Specified
System applied for.
List Qualifications that you hold in respect of each specified system applied for.
Qualifications
Date
Qualification
Awarded
Discipline
Education
Provider
Country
Year
eg Firetech Level
4
In years
As it relates to
the system
applied for
University/
Polytechnic etc
Professional Memberships/Registration/Licenses
Please list any professional or licenses that you currently hold or have previously
held. Certified copies of your membership/registration/license certificates must be
provided with your application (please attach).
Institution/
Organisation
Class
Still
current
Y/N
Membership/Registrati
on Number
Year
Gained/Joined
Expiry
Date
#840894 Page | 4
Work History Summary
Provide details of recent work history including dates of employment.
Name of
Organisation
Position Title
Date of
Employment
Key Responsibilities, Activities
Undertaken
Section C: Information used to verify compliance with Specified Systems.
Identify the standards and or inspection procedures that you intend to use for each
specified system that you have applied for. NOTE: Refer to first schedule
“Guidelines for minimum qualification and experience required for acceptance of
independent qualified person status.”
Specified System
Relevant Standard/s
Inspection Sheet
Attach evidence that you have access to each of the standards identified above.
A photo copy of the front cover will suffice. Also attach copies of
inspection/check sheets that you intend to use.
#840894 Page | 5
IQP assessment information
Demonstrate your understanding of the Building Act & Building Regulations as they
relate to compliance schedules, Building Warrants of Fitness and IQP duties.
When answering these questions refer to the Building Act 2004 sections 100-112.
http://legislation.govt.nz/act/public/2004/0072/latest/DLM306036.html and the
Compliance schedule handbook available here https://www.building.govt.nz/building-
code-compliance/building-code-and-handbooks/compliance-schedule-handbook/
IQP ASSESSMENT INFORMATION
Please complete the statements to show support of your competence level in the space below or attached
copies.
1. a) Please describe your knowledge of the compliance schedule and building warrant of fitness process.
b) include how you have gained your knowledge and over what period of time.
2. What are the key factors in determining whether a form 12A Certificate of Compliance with inspection,
maintenance, and reporting procedures can be issued?
3. When would it be appropriate to send in a report to support your 12a certificate?
4. In what circumstances would you consider change to a compliance schedules and specified systems?
#840894 Page | 6
Section D: Supporting Statements:
Attach supporting technical references from individual, professional/technical
institutes (a minimum of one written reference is required for each systems or
feature applied for).
Referees should be qualified in the discipline for which they are providing the
reference. Referees may be contacted during the processing of the application.
Referees:
Name two referees who are familiar with your activities and can provide comments as
to whether you demonstrate competence in elements of your relevant field. Referees
must be independent. i.e. not personally related to you and not expected to gain
materially if your assessment is successful. One of your referees may be from your
organisation.
Ideally one of your referees could be an IQP in the relevant field
Tick the box to confirm
Completed Referees Declaration and Evaluation Form 1 attached.
Referees
Name:
Referees
Name:
Address:
Address:
Telephone:
Telephone:
Email
Address:
Email
Address:
IQP No.
IQP No.
Known registration and professional body
membership:
Known registration and professional body
membership:
Section E: Insurance
Public Liability or Professional Indemnity Insurance held relative to the role of an
Independent Qualified Person. Please provide a copy of the certificate of cover.
Type of Cover
Amount
Insurer
Exclusions
#840894 Page | 7
QUALITY ASSURANCE
Are you/your organisation accredited in a recognised quality standard
e.g. ISO/IANZ.
If so please provide a description and a copy.
Yes
No
Do you or your company use check/prompt sheets for each type of
inspection for which you have applied for.
If so please attach those that apply to your current application.
Yes
No
Is any measuring equipment you use regularly calibrated?
If so please identify the equipment and the process of how it is
calibrated.
Yes
No
Section F: Statement about Application
I am applying for approval to be on the South Island IQP register.
I acknowledge that the South Island IQP registration panel may cancel my approval at
anytime subject to their disciplinary procedures.
I acknowledge that if my application is accepted my contact details will be on the
IQP register which is available to the public.
I acknowledge that I will manage any potential conflict of interest.
If you intend supervising a person who is not a suitably registered IQP, please
provide the following information:-
Records of how this supervision is achieved.
I certify that all information I have provided in this application is true and accurate.
Signature: ....................................................... Date: ...............................................
Send your completed application to the address set out below:
South Island IQP Register
PO Box 522
Timaru 7940
click to sign
signature
click to edit
#840894 Page | 8
Fees and Chargers for IQP Processing all inclusive of GST
Application – Individual (one system only)
$280.00
Per each additional system
$20.00
Annual Renewals
$120.00
Please note: Fees must be paid before an application can be processed and
passed onto the panel for consideration. For payment options please see page
11
The following information is attached to this application (tick in box)
Evidence of current Professional membership ......................................
Copies of Standards to be used ............................................................
Copies of Check Sheets .......................................................................
Details of Insurance Cover ....................................................................
Copy of Quality Assurance system ........................................................
Referees Declaration and Evaluation (Form 1) ...................................
#840894 Page | 9
REFEREES DECLARATION AND EVALUATION
(Form 1)
Completed Peer assessment of:
....................................................................................................................................
Full Name of referee:
....................................................................................................................................
I declare that I personally attest to the competence of the individual named above.
This constitutes my personal and independent evaluation of the individuals
competence in regard to the area of expertise.
I am an individual of at least equivalent competence.
The nature and extent of my professional contact with the individual in the last five
years is as follows:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
I have experience in the following areas:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Referees Signature: ..................................................... Date: ................................................
Referees Phone Number:.........................................................................................................
Referees e-mail: ........................................................................................................................
click to sign
signature
click to edit
#840894 Page | 10
REFEREES DECLARATION AND EVALUATION
(Form 1)
Completed Peer assessment of:
....................................................................................................................................
Full Name of referee:
....................................................................................................................................
I declare that I personally attest to the competence of the individual named above.
This constitutes my personal and independent evaluation of the individuals
competence in regard to the area of expertise.
I am an individual of at least equivalent competence.
The nature and extent of my professional contact with the individual in the last five
years is as follows:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
I have experience in the following areas:
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Referees Signature: ..................................................... Date: ................................................
Referees Phone Number:.........................................................................................................
Referees e-mail: ........................................................................................................................
#840894 Page | 11
PAYMENT OPTIONS
You can either pay by coming into the Timaru District Council, posting in a
cheque or online
Cheque Payments
IQP Secretary SI
Timaru District Council
PO Box 522
Timaru 7940
Online
When paying online please put IQP Application Fee in as reference and name
of applicant
Account Details for Direct Credit Payment
Timaru District Council
BNZ Timaru
02-0888-0269159-00
(A Tax Invoice is also available if required)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application for Acceptance as an Independent Qualified Person (Timaru District Council New Zealand)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document