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09/40949 28 June 2016 1
Building Consent Application
Compliance Schedule Information
This form is to accompany applications for building consent for projects involving
Compliance Schedules
Owner
Site address
Area m
2
of building
Max. occupancy load
Highest fire hazard category
Please provide numbered plans showing the location of all systems in the building. If there are multiple
buildings on the same site, please provide name and location of building.
Part 1
Specified Systems or Features Involved In the Project Please the appropriate box
SS Number
System or feature
Altered
Added To
Removed
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
09/40949 28 June 2016 2
SS Number
System or feature
Altered
Added To
Removed
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
SS 8/2
Service lifts
SS 8/3
Escalators and moving walks
SS 9/1
Mechanical ventilation - toilet or
kitchen extract system
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
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
09/40949 28 June 2016 3
SS Number
System or feature
Altered
Added To
Removed
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
SS 16/1
Cable car carriage of people
SS 16/2
Cable car carriage of goods
09/40949 28 June 2016 4
Part 2
Detailed Information about the Systems/Features involved in the Project
Please complete one of the boxes below for each system or feature listed in part 1.
The box below is an example of the information required
EXAMPLE
SS number
SS 2/1
System or feature
Manual Emergency Warning System
Type
Type 2f
Make & Model
Pertronic F1-3 fire alarm system. Including PL/22 Panel (model F10,
PL 620 manual call points (model CPPIN-3T), PL/6639 alerting
devices (model P331/W), and SS/328 smoke detectors (model 2151
BPI). Alarm is not brigade connected.
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
In buildings numbered 5 and 6 on site plan number ______
Located as marked on floor plan number _______
Performance Standard
NZS4512:2003
Inspections Procedure
Monthly inspection and annual inspections as per NZS4512; 2003
Monthly inter face with the following specified systems
Sprinkler system
Auto doors access controlled doors
Fire/ smoke doors
Lifts
Mechanical ventilation
Maintenance Procedures
Planned preventative maintenance and responsive maintenance
should be carried out in accordance with NZS4512:2003 and to
ensure the system will operate as required in the event of fire
Persons Responsible
All inspections shall be undertaken by independent qualified persons.
Reporting Procedures
The owner must keep records of all inspection, maintenance and
repairs undertaken in the previous 24 months. The records must, as a
minimum, include: details of any inspection, test or preventative
maintenance carried out, including dates, work undertaken, faults
found, remedies applied, and the person who performed the work
details of any other faults found or maintenance and repair work
undertaken to maintain the system in working order, including dates,
work undertaken, faults found, remedies applied and the person who
performed the work.
09/40949 28 June 2016 5
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
09/40949 28 June 2016 6
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
09/40949 28 June 2016 7
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
09/40949 28 June 2016 8
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
SS number
System or feature
Type
Make & Model
Location in building
(state building name if more than one
building and refer to drawing
reference where appropriate)
Performance Standard
Inspections Procedure
Maintenance Procedures
Persons Responsible
Reporting Procedures
Form completed by:
Name:
Signature:
Date:
Owner/agent acting on behalf of and with the authority of the owner *
*delete that which does not apply
click to sign
signature
click to edit
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