Private Bag 9023 | Whangarei 0148 | New Zealand
T: 09 430 4200 | 0800 WDC INFO | 0800 932 463 | F: 09 438 7632
W: www.wdc.govt.nz | E: mailroom@wdc.govt.nz
06/334829 29 November 2012
Application for amendment to compliance schedule - Form 11
Section 106, Building Act 2004
Building
Street address of building
(For structures that do not have a street address, state the nearest street intersection)
Legal description of land where building is located
(State legal description as at date of application and, if land is proposed to
be subdivided, include details of relevant lot numbers & subdivision consent)
Building name
Location of building within site/block no
Current, lawfully established, use
Include number of occupants per level and per use if more than 1
Owner
Name of owner
Contact person
Mailing address
Street address/registered office
Phone numbers
Landline
Mobile
Daytime
After hours
Email
Fax
Website
Evidence of ownership
(Copy of certificate of title, lease, agreement for sale and purchase, or other document showing full name
of legal owner(s) of building)
Agent
Name of agent
(If made on behalf of the owner)
Contact person
Mailing address
Street address/registered office
Phone number
Landline
Mobile
Daytime
After hours
Email
Fax
Website
Relationship with owner
(State details of the authorization from the owner to make the application on the owner’s behalf)
06/334829 29 November 2012 2
System or feature
Required performance standard
SS 1/1
Automatic system for fire suppression - water
SS 1/2
Automatic system for fire suppression - gas
SS 1/3
Automatic system for fire suppression - powder
SS 1/4
Automatic system for fire suppression - other
SS 2/1
Manual emergency warning system
SS 2/2
Automatic fire alarm type 3
SS 2/3
Automatic fire alarm type 4
SS 2/4
Automatic fire alarm type 5
SS 3/1
Automatic doors
SS 3/2
Access controlled doors
SS 3/3
Interfaced fire or smoke doors or windows
SS 4/1
Emergency lighting existing NZS 6742
SS 4/2
Emergency lighting new AS/NZS 2293
SS 4/3
Emergency lighting with generator
SS 5
Escape route pressurisation systems
SS 6/1
Riser main - dry
SS 6/2
Riser main - charged
SS 7
Automatic back-flow preventer
SS 8/1
Passenger-carrying lifts
System or feature
Required performance standard
SS 8/2
Service lifts
SS 8/3
Escalators and moving walks
SS 9/1
Mechanical ventilation - toilet extract system serving
multiple facilities
SS 9/2
A ducted ventilation or air conditioning system
SS 9/3
A spray booth ventilation system where the booth
forms all or part of the building
SS 9/4
Mechanical ventilation - an air-handling system that
maintains a differential air pressure in a hospital
operating theatre, medical isolation room,
quarantine facility or pharmaceutical manufacturing
plant
SS 9/5
A cooling-water system incorporating one or more
cooling towers or evaporative condensers
SS 9/6
An air-handling system required to function in
smoke management or smoke clearance mode
during a fire
SS 9/7
A system incorporating one or more solid liquid or
gas-fired boilers
06/334829 29 November 2012 3
SS 9/8
Air conditioning system- containing one or more
electric heating elements mounted in air handling
units or ducts located outside the occupied space
SS 9/9
Air conditioning system- a split air conditioning unit
that introduces fresh air into the building
SS 10/1
Building maintenance unit - suspended
SS 10/2
Building maintenance unit travelling ladder or
gantry
SS 11
Laboratory fume cupboard
SS 12/1
Audio loops
SS 12/2
FM radio frequency systems and infrared beam
transmission systems
SS 13/1
Mechanical smoke control
SS 13/2
Natural smoke control
SS 13/3
Smoke curtains
SS 14/1
Emergency power systems
SS 14/2
Signs
S 15/1
Systems for communicating spoken information
intended to facilitate evacuation
SS 15/2
Final exits
SS 15/3
Fire separations
SS 15/4
Signs for communicating information intended to
facilitate evacuation
SS 15/5
Smoke separations
System or feature
Required performance standard
SS 16/1
Cable car carriage of people
SS 16/2
Cable car carriage of goods
06/334829 29 November 2012 4
Amendment required
Type Specified System
(mandatory)
Make
Location
Reason
Type Specified System
(mandatory)
Make
Location
Reason
Type Specified System
(mandatory)
Make
Location
Reason
Type Specified System
(mandatory)
Make
Location
Reason
Attachments
Compliance Schedule - Site Audit Sheet (Please complete and return)
Copy of existing Compliance Schedule
Signed by owner/agent on behalf of, and with the authority of the owner
Signature
Name (Please print)
Date
Private Bag 9023 | Whangarei 0148 | New Zealand
T: 09 430 4200 | 0800 WDC INFO | 0800 932 463 | F: 09 438 7632
W: www.wdc.govt.nz | E: mailroom@wdc.govt.nz
12/94159 29 November 2012
Site Audit Sheet
Compliance Schedule No:
Section 103, Building Act 2004
Street address of building
Legal description of land where
building is located
Building name
Location of building within
site/block number
Level/unit number
Maximum occupancy load per level
Current, lawfully established, use
Year first constructed
Intended life of the building if
50years or less
Highest fire hazard category of
building
Current use related to crowd
activities: (circle applicable use)
CS
SH
CL
WL
CO
WM
CM
WH
SC
WF
SD
IA
SA
ID
SR
12/94159 29 November 2012 2
CS System Template
System name
Type
(photos acceptable)
Make/model
Location
(photos acceptable)
Number
Performance standard
Inspections
Maintenance
Frequency
Persons responsible
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