D10/25042 Version 2 AUTHORITY TEMPLATE - APPLICATION - IQP - BC 20 IQP Application Form
APPLICATION FOR ACCEPTANCE AS AN
INDEPENDENT QUALIFIED PERSON
INFORMATION FOR PERSONS SEEKING ACCEPTANCE BY THE STRATFORD DISTRICT COUNCIL
AS INDEPENDENT QUALIFIED PERSONS FOR THE PURPOSES OF SECTIONS 7 AND 103 OF THE
BUILDING ACT 2004
The Council is required to determine that "Independent Qualified Persons" are appropriately qualified to
undertake the inspection and maintenance of Specified Systems as defined in Section 7 or listed in
Section 103 of the Building Act 2004, for buildings within its area.
The applicant is required to provide sufficient documented evidence of appropriate qualifications to
undertake the inspection and maintenance of the feature or systems for which approval is sought.
Further information may be requested during the consideration of an application.
The following information is required:
(a) Applicant's name and address.
(b) Features and/or systems for which acceptance is sought.
(c) Details of insurance cover held.
(d) Qualifications - by examination.
- by training (apprenticeships, courses etc.).
(e) Refresher courses etc. since qualifications obtained.
(f) Membership of any professional institutes or technical organisations.
(g) Related experience - full relevant employment history.
(h) Related technical references - may include individuals, institutions, clients etc. A minimum of
three are required. Further reference may be made to referees during consideration of the
application.
(i) A brief summary of the procedures the applicant would adopt in the inspection and maintenance
of the features or systems for which acceptance is sought, together with advice as to the relevant
New Zealand standards, technical documents etc. against which performance would be checked.
NOTE: For other than individual applicants, ie. the Crown, corporations etc. the information required in
(c) –
(h) should be supplied in respect of an individual within the organisation appropriate qualified.
D10/25042 Version 2 AUTHORITY TEMPLATE - APPLICATION - IQP - BC 20 IQP Application Form
APPLICATION FOR ACCEPTANCE AS AN
INDEPENDENT QUALIFIED PERSON
(SECTION 108(3)(c) BUILDING ACT 2004)
Applicant:
Company:
Postal Address:
Landline:
Mobile:
Email:
PART A : QUALIFICATIONS AND EXPERIENCE
NOTE: For other than individual applicants, ie. companies, corporations etc. the information required in
Parts B and C should be supplied in respect of an individual within the organisation appropriately qualified
to inspect and maintain each system or feature for which acceptance is sought. (Please copy this form as
necessary).
Applicant's Relevant Qualifications and Experience
Qualifications by Examination Granted By Date Granted
Membership of Professional Institutions and
Technical Organisations
Date
Admitted
Qualification by Training not Included
Above (Apprenticeships, Courses etc.)
Organised or
Supervised By
From To
Refresher Courses not Included Above Organised or
Supervised By
From To
Experience From To
APPROPRIATE DOCUMENTED CONFIRMATION OF THE ABOVE IS REQUIRED AND SHOULD
ACCOMPANY THE APPLICATION
D10/25042 Version 2 AUTHORITY TEMPLATE - APPLICATION - IQP - BC 20 IQP Application Form
PART B : SCOPE
Systems or features for which acceptance as an Independent Qualified Person is sought:
Specified System
SS1 Automatic systems for fire suppression.
SS2 Emergency warning systems.
SS3/1 Automatic door.
SS3/2 Access controlled doors.
SS3/3 Interfaced fire or smoke doors or windows.
SS4 Emergency lighting systems.
SS5 Escape route pressurisation systems.
SS6 Riser mains for use by fire services.
SS7 Automatic back-flow preventers connected to a potable water supply.
SS8/1 Passenger carrying Lifts.
SS8/2 Service Lifts.
SS8/3 Escalator and moving walks.
SS9 Mechanical ventilation or air conditioning systems.
SS10 Building maintenance units.
SS11 Laboratory fume cupboards.
SS12/1 Audio loops.
SS12/2 FM radio and infrared beam transmission systems.
SS13/1 Mechanical smoke control.
SS13/2 Natural smoke control.
SS13/3 Smoke curtains.
SS14/1 Emergency power systems.
SS14/2 Signs for SS1-13.
SS15/1 Spoken information to facilitate evacuation.
SS15/2 Final exits.
SS15/3 Fire separations.
SS15/4 Signs for facilitating evacuation.
SS15/5 Smoke separations.
SS16 Cable cars.
D10/25042 Version 2 AUTHORITY TEMPLATE - APPLICATION - IQP - BC 20 IQP Application Form
PART C: SUPPORTING STATEMENTS
Supporting technical references attached from individuals, professional or technical institutions, clients
etc. (A minimum of three covering all systems or features for which acceptance is sought.) Referees
may be contacted during the processing of the application.
Name and Address
System or Feature to which
Reference Relates
Brief summaries attached outlining the procedures to be adopted in the inspection and maintenance of
each feature or system for which acceptance is sought, together with advice as to the relevant New
Zealand standards, technical documents etc. against which performance would be checked.
PART D : INSURANCE
Public liability or professional indemnity insurance held relative to the role of an independent qualified
person.
Type of Cover Amount Insurer Significant Exclusions
PART E: DECLARATION
I of solemnly and sincerely declare that the statements contained
(insert full name) (insert company)
in this form are true, and I make this solemn declaration conscientiously believing the same to be true and
by virtue of the Oaths and Declarations Act 1957.
SIGNED:
DATE:
(Applicant)
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