Fillable CS9.1 Certificate for Public Use Checklist (Queenstown Lakes District Council New Zealand)

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CS9.1 Certificate for Public Use Checklist (Queenstown Lakes District Council New Zealand)

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The CS9.1 Certificate for Public Use Checklist (Queenstown Lakes District Council New Zealand) form is 3 pages long and contains:

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  • 55 check-boxes
  • 40 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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CS9.1 Page 1 of 3 Last Updated: 07/03/2018
Revision: 1
CS9.1 Certificate for Public Use Checklist
Building Consent Number(s):
Premises
(Description of premises for which certificate is
issued):
Name of applicant:
(Person who owns, occupies or controls the
premises)
Contact Person:
☐ Owner
☐
Agent
Mailing Address:
The following checklist details the items and information that is required for a new Certificate for Public Use
(CPU) application or renewal (Section 363A, Building Act 2004).
Please complete this form and provide a copy with your CPU application. The notes in this form will provide
evidence that the building is safe to occupy while building work is being carried out.
An incomplete application or lack of supporting information will mean that your application cannot be
accepted for processing and an inspection will be refused which will delay the issue of the CPU.
Applicant to Complete Council Use Only
Yes
N/A Description Yes RFI Checking comments
☐
FORM 15 CPU APPLICATION
Form 15 Application for Certificate for Public Use filled out
completely
☐ ☐
☐
PLANS
Plans
showing area subject to the CPU and showing any
additional safety measures in place for proposed duration of
the CPU
☐
☐
☐ ☐
COMPLIANCE SCHEDULE
☐ Form 27 Application for Compliance Schedule
☐ Form 11 Amendment to Compliance Schedule
☐ ☐
☐
SS Forms- Provide details of all SS forms supplied below:
Note: Completed SS forms are to be supplied for all specified
systems to enable issue of a new compliance schedule (or
amended compliance schedule if there is one in place
already). Where a system is not fully functional or is subject
to interruption over the duration of the CPU an explanation of
how this will be managed is required to be supplied
CS9.1 Page 2 of 3 Last Updated: 07/03/2018
Revision: 1
CS9.1 Certificate for Public Use Checklist
Applicant to Complete Council Use Only
Yes
N/A Description Yes RFI Checking comments
☐
☐
STRUCTURE (B1)
PS4 from supervising structural engineer. If a PS4 is not
available a letter from the engineer explaining that the area
subject to the CPU is safe may be accepted. This letter would
need to outline any temporary measures, if any, such as
propping which are required
☐
☐
Information provided:
☐ ☐
FIRE SAFETY (C1 –C6, F6, F7)
Analysis of means of escape from fire including egress paths,
route changes, passive fire integrity measures and any
proposed compensatory measures. Commissioning and
where necessary independent certification of emergency
lighting, warning and suppression systems provided.
Where the building is required to have a Fire and Emergency
NZ (FENZ) approved evacuation scheme evidence of this is to
be provided. Alternatively a letter of support for th
e CPU
from FENZ may be accepted
☐
☐
Information provided:
☐ ☐
ACCESS (D1 & D2)
Safe entry into and through the parts of the building covered
by the CPU demonstrated on a plan for all users including
persons with disabilities. Certification provided for any
mechanical installations to be used for access within the area
covered by the CPU
☐ ☐
Information provided:
☐ ☐
SAFETY FROM FALLING (F4)
Evidence that required barriers in the area subject to the CPU
are in place
☐ ☐
Information provided:
CS9.1 Page 3 of 3 Last Updated: 07/03/2018
Revision: 1
CS9.1 Certificate for Public Use Checklist
Applicant to Complete Council Use Only
Yes
N/A Description Yes RFI Checking comments
☐
☐
CONSTRUCTION HAZARD (F5)
Explanation of how people in the area subject to the CPU are
protected from construction and demolition hazards
☐
☐
Information provided:
☐ ☐
PERSONAL HYGIENE (G1)
All sanitary facilities, including accessible facilities
operational, compliant and available in the area subject to the
CPU
☐ ☐
Information provided:
☐
☐
VENTILATION (G4)
Commissioning statements and PS3s provided for ventilation
systems
☐
☐
☐ ☐
ELECTRICITY (G9)
Certification of compliance from registered electrician
provided
☐ ☐
☐ ☐
GAS (G11)
Certification of compliance from certifying gasfitter provided
☐ ☐
☐
☐
WATER SUPPLIES (G12)
Commissioning statements for backflow preventers provided,
safe water temperatures at personal hygiene fixtures
provided and circulating hot water systems are protected
against legionella.
☐
☐
Information provided:
By signing below I acknowledge that following issue of this Certificate for Public Use I have a responsibility to ensure the
inspection, maintenance and testing requirements of the specified systems and the final exits are adhered to as per the
compliance schedule.
In addition as the person responsible for the safety of the people in the building at all times I confirm I have procedures
in place that will ensure the continued safe operation of the building
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CS9.1 Certificate for Public Use Checklist (Queenstown Lakes District Council New Zealand)

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Completed 10 November 2020

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