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06/704164 October 2010
Certificate of compliance with inspections, maintenance & reporting
procedures
Form 12A (Section 108 (3) (c) Building Act 2004)
Building
Street address of building
Building name
Compliance schedule no
Level/unit no
Annual BWOF expiry date
Location of building within site/block no
Owner
Name of person
Contact person
Mailing address
Street address/registered office
Compliance
The inspection, maintenance & reporting procedures of the compliance schedule have been fully complied
with during the 12 months prior to the date stated below, in relation to the following specified item(s)
Name of licensed building practitioner (please print)
Name of LBP/IQP company
LBP/IQP no
Signature of licensed building practitioner
Date
06/704164 October 2010 2
System
1
Automatic system for fire suppression
2
Automatic or manual emergency warning systems
3
Electromagnetic or automatic doors or windows
3/1
Automatic doors
3/2
Access controlled doors
3/3
Interfaced fire or smoke doors or windows
4
Emergency lighting systems
5
Escape route pressurisation systems
6
Riser mains
7
Automatic back-flow preventers
8
Lifts, escalators, travelators or similar systems for moving people or goods within buildings
8/1
Passenger carrying lifts
8/2
Service lift
8/3
Escalators and moving walks
9
Mechanical ventilation or air conditioning systems
10
Building maintenance units
11
Laboratory fume cupboards
12
Audio loops or other assistive listening systems
12/1
Audio loops
12/2
FM radio frequency systems and infrared beam transmission systems
13
Smoke control systems
13/1
Mechanical smoke control
13/2
Natural smoke control
13/3
Smoke curtains
14
Emergency power systems for or signs relating to, a specified system in any of specified systems
1-13
14/1
Emergency power for a system or feature specified in any of clauses 1 to 13
14/2
Signs relating to a system or feature specified in any of clauses 1 to 13
15
Other fire safety systems or features, so long as they form part of a building’s means of escape from
fire & those means also contain any or all of the systems or features specified in clauses 1 to 6 & 13
15/1
Systems for communicating spoken information intended to facilitate evacuation
15/2
Final exits (as defined by clause A2 of the building code)
15/3
Fire separations (as so defined)
15/4
Signs for communicating information intended to facilitate evacuation
15/5
Smoke separations (as so defined)
16/1
Cable cars carriage of people
16/2
Cable cars carriage of goods
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