FORM6V923/10/2014
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FORM 6 **Please complete all sections relevant to your building consent.
APPLICATION FOR
CODE COMPLIANCE CERTIFICATE
Section 92, Building Act 2004
Building Consent No: ________________________ Issued by: ____________________________________
Location: _________________________________ Description of work: ________________________________
The Owner
Contact
Only complete if you are making the application on behalf of the Owner.
Owners Name:
Postal Address:
Street Address/
Registered Office:
Co
ntact Person:
Landline:
Daytime:
After Hours:
Mobile:
Fax:
Email:
Website:
_________________________
_________________________
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_________________________
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_________________________
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_________________________
Contacts Name:
Postal Address:
Street Address/
Registered Office:
Contact Person:
Landline:
Daytime:
After Hou
rs:
Mobile:
Fax:
Email:
Website:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
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____________________________
First Point of Contact for communications with
Council:
Owner
Contact
First Point of Contact for communications with Council:
If different to the Owner & Contact details above
Contacts Name:
Postal Address:
Landline:
Daytime:
________________________
________________________
________________________
________________________
________________________
After Hours:
Mobile:
Fax:
Email:
____________________________
____________________________
____________________________
____________________________
The following evidence of ownership is attached to this application showing full name of legal owner(s) of
the building:
Copy of certificate of title
Agreement for sale and purchase
Lease
Other (specify) __________________________________
Application:
All building work to be carried out under the above building consent was completed on: ___________________
dd/mm/yyyy
FORM6V923/10/2014
Page 2 of 3
The licensed building practitioner(s) (LBP’s) who carried out or supervised the restricted building work
is/are as follows:
Restricted Building Work (RBW) involved
**Please complete the below section listing the LBP’s involved.
No Restricted Building Work (RBW) involved
**Please do not fill in this section & proceed to the next section.
Name
Licensing
Class
Licensed building
practitioner number
(or registration number if treated as
being licensed under Section 291 of
Building Act 2004)
Particular work carried out or
supervised
The personnel who carried out building work other than restricted building work are as follows:
Name Area of Work
Registration Number
**For example Certifying Plumber,
Drainlayer, Registered Electrician, etc.
Particular work carried out or
supervised
The following specified systems are contained on the compliance schedule for the building and, in the
opinion of the personnel who installed them, are capable of performing to the performance standards set
out in the building consent:
Residential Building
**Please do not fill in this section & proceed to the next section
unless the building includes a cable car
Commercial/Industrial Building
**Complete the below section listing specified systems if you have an
existing compliance schedule.
SS 1
Automatic Systems for Fire
Suppression
SS 10
Building Maintenance Units
SS 2
Emergency Warning Systems
SS 11
Laboratory Fume Cupboards
SS 3.1
Automatic Doors & Windows
SS 12.1
Audio Loops
SS 3.2
Access Controlled Doors
SS 12.2
FM Radio Frequency Systems
SS 3.3
Interfaced Fire / Smoke Doors /
Windows
SS 13
Mechanical Smoke Control
SS 4
Emergency Lighting Systems
SS 14.1
Emergency Power Systems for SS 1 13
SS 5
Escape Route Pressurisation
Systems
SS 14.2
Signs for SS 1 13
SS 6
Riser Mains
SS 15.1
Systems for Communicating Evacuation
SS 7
Auto Backflow Preventers
SS 15.2
Final Exits
SS 8.1
Passenger Carrying Lifts
SS 15.3
Fire Separations
SS 8.2
Service Lifts
SS 15.4
Signs
SS 8.3
Escalators & Moving Walks
SS 15.5
Smoke Separations
SS 9
Mechanical Vent / Air Con Systems
SS 16
Cable Cars
FORM6V923/10/2014
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I request that you issue a code compliance certificate for this work under Section 95 of the Building Act
2004.
___________________________________________________________________________________________
Signature of owner/agent Name of Person Date
on behalf of and with the authority Signing
of the owner (delete one)
The code compliance certificate should be sent to:
Owner; Agent detailed above; or
Other (specify) __________________________________
Attachments: Please tick all items that are applicable
Records of Work (ROW) from LBP’s
As built truss plans & layout
Other documents from personnel who carried out
work
(e.g. Producer Statements)
Evidence that specified systems are capable of
performing to the performance standards set out in the
building consent
Energy Works Certificates
As built drainage plan
Office Use only: Received by: (initial) __________ Date: ____________________
Entered into computer system
20 day monitoring started.
All inspections undertaken?
Yes
No
If no, inspection booked for: ____________________________________
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