Fillable Form 11: Application for amendment to Compliance Schedule (Queenstown Lakes District Council New Zealand)

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Form 11: Application for amendment to Compliance Schedule (Queenstown Lakes District Council New Zealand)

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The Form 11: Application for amendment to Compliance Schedule (Queenstown Lakes District Council New Zealand) form is 2 pages long and contains:

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Form 11
Form 11 (Revision: 8) Page 1 of 2 Last Updated: 03/03/2020
Application for amendment to Compliance
Schedule (without building consent)
Section 106, Building Act 2004. Building (forms) Regulations 2004
Th
is form is to be used to request an amendment to a compliance schedule outside of a building consent. The territorial
authority (TA) will review the application and make a decision to either amend the compliance schedule or refuse with reasons.
Please identify specified system(s) to be amended on page 2 with reasons for amendment (e.g. as a result of an audit by the TA)
and complete a SS form for each amended system stating design, installation, reporting and maintenance procedures. Our
website has information that may be of assistance please see Information Sheet on Specified System (IS SS)
1 THE BUILDING
Street address of the building for structures without a street address, state the nearest street intersection and distance from that intersection
Legal description of land where building is located state legal description as at the date of application and, if the land is proposed to be subdivided,
include details of relevant lot numbers and subdivision consent
Current, lawfully established, use in terms of the building code clause A1 Classified uses (include number of occupants per level and pre use if more than 1)
Compliance Schedule Number Level / Unit number Building name and location within site/block to nearest street access
2 OWNER
Name of owner Contact person if not owned by an individual
Contact details
Phone number(s) Email / Website Mailing address & Street address (if different)
Proof of ownership
Record of Title Lease Agreement Sale & purchase agreement Other document
3 AGENT / APPLICANT only required where the application is being made on behalf of the owner
Name of agent / applicant Contact person if the agent / applicant is not an individual
Contact details
Phone number(s) Email / Website Mailing address & Street address (if different)
Confirm relationship to owner & authorisation to act
First point of contact for communication with the council: Billing (Payer) Details
Agent Owner Other (provide details) Agent Owner Other (provide details)
Form 27 (Revision: 8) Page 2 of 2 Last Updated: 03/03/2020
I request that the compliance schedule for the above building be amended as follows;
Select specified system(s) be amended
Reason for amendment
☐
SS 1 Automatic systems for fire suppression
☐
SS 2 Automatic or manual emergency warning systems for fire or other dangers
SS 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
☐
SS 4 Emergency lighting systems
☐
SS 5 Escape route pressurisation systems
☐
SS 6 Riser mains for use by fire services
☐
SS 7 Automatic backflow preventers connected to a potable water supply
SS 8 Lifts, escalators, travelators, or other systems for moving people or goods
☐
8/1 Passenger-carrying lifts
☐
8/2 Platform, Low Speed & Service Lifts
☐
8/3 Escalators and Moving Walks
☐
SS 9 Mechanical ventilation or air conditioning systems
☐
SS 10 Building maintenance units (access to the exterior and interior walls of a building)
☐
SS 11 Laboratory fume cupboards
☐
SS 12 Audio loops or other assistive listening system
SS 13 Smoke Control Systems
☐
13/1 Mechanical Smoke Control
☐
13/2 Natural Smoke Control
☐
13/3 Smoke Curtains
SS 14 Emergency Power Systems for, or signs relating to, a specified system and any of specified systems 1-13
☐
14/1 Emergency power systems
☐
14/2 Signs
SS 15 Other fire safety systems or features (contains one or more specified systems 1–6, 9 and 13)
☐
15/1 Systems for communicating spoken information intended to facilitate evacuation
☐
15/2 Final Exits
☐
15/3 Fire Separations
☐
15/4 Signs for communicating information intended to facilitate evacuation
☐ 15/4 Signs not-illuminated
☐ 15/4 Signs Illuminated
☐
15/4 Photoluminescent signs and escape path marking
☐
15/5 Smoke separations
☐
SS 16 Cable cars
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Form 11: Application for amendment to Compliance Schedule (Queenstown Lakes District Council New Zealand)

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Completed 10 November 2020

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