Doc # 308498 Page 5 of 5 BA Form 6
Riser mains for Fire Service use
Any automatic back-flow preventer connected to a potable water supply
Lifts, escalators, travelators or other systems for moving people or goods within buildings
Mechanical ventilation or air-conditioning systems
Building maintenance units for providing access to the exterior and interior walls of buildings
Laboratory fume cupboards
Audio loops or other assistive listening systems
Smoke control systems
Emergency power systems for, or signs relating to, a system or feature specified
Systems for communication spoke information intended to facilitate evacuation
Final exits ( as defined by clause A2 of the Building Code )
Fire separations ( as defined by clause A2 of the Building Code )
Signs for communicating information intended to facilitate evacuation
Smoke separations ( as defined by clause A2 of the Building Code )
I request that you issue a Code Compliance Certificate for this work under Section 95 of the Building Act 2004.
The Code Compliance Certificate
should be sent to: (state which address
and whether owner or agent)
Signed by the owner: OR Signature:
Signed by the agent:
(on behalf of, or
with authority from the owner)
G. ATTACHMENTS - please tick those that are relevant and attached
Memoranda (Records of Building Work) from licensed building practitioner(s) stating what restricted building work they
carried out or supervised.
Other documents from the personnel who carried out the work.
Evidence that specified systems are capable of performing to the performance standards set out in the building consent.
Energy works certificates (electrical, gas etc).