Fillable Form 2: Application for project information memorandum: and/or (Queenstown Lakes District Council New Zealand)

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Form 2: Application for project information memorandum: and/or (Queenstown Lakes District Council New Zealand)

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Form 2: Application for project information memorandum
and/or building consent
Section 33 or 45, Building Act 2004
1. THE BUILDING [Complete all applicable sections]
2. APPLICATION [Nominate as applicable]
3. THE PROJECT
Street addr
ess of building: ………………………………………………………….…..……………….……..….…...........................................................…
.....…………………………………………………………………………………...................................................................….
[If no
street address – details of nearest intersection] ………………………….……………….……………………….……….............................................................…
Legal description of land where building is located: Lot ………………………. DP………………...………….
Site area ……………… (m
2
) Sec ………………………. Block……………...…………
Building name: ……….…………………….……… Valuation Number ………………………….……………….
Location
of building within site/block number: [Include nearest street access] …………………………….……………..........................................................…
Number of levels: [Above & below ground] ………………..………..….. Level /Unit Number: …………..……………
Year First Constructed:....................... Floor area: …………………..…..… (m
2
) [Indicate area affected by the building work]
Current, lawfully established, use as defined in the building code clause A1 Classified uses
[Add no. of occupants per level and per use if more than 1]
:
……………………………………………..……………………………….........................................................................…….............................................................................................……
………………………………………………………………………………………………………………………………
Year first constructed: [Approximate date is acceptable e. g.: c1920s or 1960-1970] ……………………………………
I request that you issue a: (for the building work described in this application)
Project Information Memora dum (PIM)
Project Information Memorandum (PIM) and Building Consent (BC)
Building Consent The existing PIM No [If applicable] is: …..………..……………….
Amendment to an existing Building Consent. The existing BC No is: ………………….……..…
Staging of building work – Being stage ……….. of ……….. stages
State the reference number if this application involves a National Multiple Use Approval: ……………………………………….…………
Name: …………………….………………….……Signature: …………….….…………………………Date: ………….…..……
The signature is that of the Owner OR the Agent on behalf of and with the approval of the Owner
DESCRIPTION OF BUILDING WORK: (Provide sufficient information below to enable scope of work to be fully understood)
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
……….…………………….……………………….……………………….………..…………….…………………….……………………………………………
Current use of building (as defined by Change the Use Regulations).....................................................................................................
Will the building work result in a change of use of the building? Yes No. If Yes, provide details of the new use of the building:
…………………………………………………………………………………..........………………………………………………………………………………
Intend
ed life of the building if less than 50 years: ……………… [Years]
List Building Consents previously issued for this project (if any): …………………………………………………………………………………………………...…
Estim
ate
d value of the building work on which the building levy will be calculated (including goods and services tax):
$....
............................................................ [State estimated value as defined in section 7 of the Building Act 2004]
FORM 2 Rev. 10
Updated 26/11/2019
Page 1 of 4
click to sign
signature
click to edit
4. OWNER 5. AGENT [Only required If application is being made on behalf of the owner]
5. THE BUILDING [If item is not applicable put NA in the space]
6. RESTRICTED BUILDING WORK
7. PROJECT INFORMATION MEMORANDUM [Do not fill in this section if the application is for a building consent only]
Name of Owner: …………..............…………...…………...................
Contact person ……………….………………….…….…..…………….
Mailing address: ……….…………………………………..……………
……………………………………..……………………..……..…..……..
Street address/registered office: ……………………………………….
……….………..…………………………………………..…….…………
Phone No.: Landline: ………………………….……………….…….
Mobile: …………………………….………..….………
Daytime: ………………………….……………...………
After hours: …………………….………………..….………
Facsimile: ………………………………..………….……
Email: ……………………………………………………………………...
Website: ………………………………………………………..….………
T
HE FOLLOWING EVIDENCE OF OWNERSHIP IS ATTACHED:
Record of Title Lease Agreement
Agreement for Sale and Purchase Other document
FIRST POINT OF CONTACT for communications with the Council / Building Consent Authority: Owner Agent
Email: Or : (If different to above details) Name :………………………………………………….. …………………………………………………..
Facsimile: Phone: Mailing Address:……………………………………………………… …………………..……. ……………………….
…………………………………………..…………
BILL
ING (PAYER) DETAILS: Owner Agent Other, (state name & email address) ……………………………………………………...
……………………………………………………………………………………………………
Name of Agent: …………………………………….........................………
Contact person: …………………………………..….……….….…………
Mail address: ………………………………………………….….…………
……………………………………..……………………..……..….….……..
Street address/registered office: ………………………………………….
……….………..……………………………………………..……..…………
Phone No.: Landline: ………………………….…………….…….…….
Mobile: …………………………….…………...…………
Daytime: ………………………….………..…..…..………
After hours: …………………….……………..………………
Facsimile: ………………………………...…..…….………
Email: …………………………………………………….……..…………...
Website: ………………………………………………….……….…………
……...….…
Relationship to owner: [State details of the authorisation from the owner to make
the application on the owner’s behalf] ……………………………………………
……………………………………..……………………….…
The following matters are involved in the project: [Nominate the matters relevant to the project]
Subdivision
Alterations to land contours [e.g. digging out the site for a building platform]
New or altered connections to public utilities [e.g. Council sewer, storm water or water mains]
New or altered locations and/or external dimensions of buildings
New or altered access for vehicles
Building work over or adjacent to any road or public place
Disposal of stormwater and wastewater
Building work over any existing drains or sewers or in close proximity to wells or water mains
Other matters known to the applicant that may require authorisations from the Territorial Authority: [Specify]
………………………………………………………………………………………………………………………………………………..……….…..…
FORM 2 Rev. 10
Updated 26/11/2019
Page 2 of 4
Will the building work include any restricted building work? Yes No
If Yes, provide the following details of all licensed building practitioners who will be involved in carrying out or supervising the restricted building
work (If these details are un-known at the time of the application, they must be supplied before the building work begins.):
Name
Licensed Building Practitioner Number
(or registration number if treated as being licensed under
section 291 of the Building Act 2004)
Note: Continue on another page if necessary
8. BUILDING CONSENT
THE BUILDING WORK WILL COMPLY WITH THE BUILDING CODE AS FOLLOWS:
NZS 4121
Accessible
Design
Method
Alternative Solution
Please complete
Form AF AS
Waiver/Modification
Please complete
Form AF WM
□
B1
Structure
□ B1/AS1 □ B1/AS3 □ B1/VM1 □ □
□ B1/VM4
□
B2
Durability
□ B2/AS1 □ B2/VM1 □ □
□
C1-6
Protection from fire
□ C/VM1 □ □
□ C/VM2
□C/AS1
□C/AS2
□
D1
Access routes
□ D1/AS1 □ □ D1/VM1 □ □
□
D2
Mechanical installation for
access
□ D2/AS1
□ □
D2/AS2
□ □ □
□ D2/AS3
□
E1
Surface water
□ E1/AS1 □ E1/VM1 □ □
□
E2
External moisture
□ E2/AS1 □ E2/AS2
□ E2/VM1
□ E2/VM2
□ □
□ E2/AS3
□
E3
Internal moisture
□ E3/AS1 □ □
□
F1
Hazardous agents on site
□ F1/VM1 □ □
□
F2
Hazardous building materials
□ F2/AS1 □ □
□
F3
Hazardous substances and
processes
□ F3/VM1 □ □
□
F4
Safety from falling
□ F4/AS1 □ □
□
F5
Construction and demolition
hazards
□ F5/AS1 □ □
□
F6
Visibility in escape routes
□ F6/AS1 □ □
□
F7
Warning systems
□ F7/AS1 □ □
□
F8
Signs
□ F8/AS1 □ □ □
□
F9
Restricting access to
residential pools
□ F9/AS1 □ F9/AS2
□
G1
Personal hygiene
□ G1/AS1 □ □ □
□
G2
Laundering
□ G2/AS1 □ □ □
□
G3
Food preparation and
prevention of contamination
□ G3/AS1 □ □ □
□
G4
Ventilation
□ G4/AS1 □ G4/VM1 □ □
□
G5
Interior environment
□ G5/AS1 □ □ □
□
G6
Airborne impact sound
□ G6/AS1 □ G6/VM1 □ □
□
G7
Natural light
□ G7/AS1 □ G7/VM1 □ □
□
G8
Artificial light
□ G8/AS1 □ G8/VM1 □ □
□
G9
Electricity
□ G9/AS1 □ G9/VM1 □ □
□
G10
Piped services
□ G10/AS1 □ G10/VM1 □ □
□
G11
Gas as an energy source
□ G11/AS1 □ □
□
G12
Water supplies
□
G12/AS1
□ G12/AS2
□
G12/VM1
□ □
□
G13
Foul water
□
G13/AS1
□ G13/AS2 □ G13/VM1 □ □
□ G13/AS3 □
G13/VM4
□
G14
Industrial liquid waste
□ G14/AS1 □ G14/VM1 □ □
□
G15
Solid waste
□ G15/AS1 □ □
□
H1
Energy efficiency
□ H1/AS1 □ H1/VM1 □ □
□
B1-H1
Simple House Solution
□ SH/AS1
□
B1-H1
Back Country Hut
□ BCH/AS1
Acceptable Solution
Nominate relevant clauses
Means of Compliance
Nominate relevant compliance path(s) for each clause selected.
Verification
Building Code Clause
The following plans and specifications are attached to this application: (please enter these in section 10 over page)
FORM 2 Rev. 10
Updated 26/11/2019
Page 3 of 4
□
□
9. COMPLIANCE SCHEDULE (Building (Specified Systems, Change the Use, and Earthquake-prone Buildings Regulations 2005)
10. ATTACHMENTS
11. CONTACTS (involved in this project)
The following documents are attached to this application (All plans and specifications must meet the minimum requirements set out in the
regulations or required by the building consent authority):
[Nominate as applicable]
Plans and specifications (list) (or attach a list)………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………..
Memoranda from licensed building practitioner(s) who carried out or supervised any design work that is restricted building work
Project Information Memorandum Development contribution notice Certificate attached to Project Information Memorandum
Other information relevant to this application: [Please specify]: …………………………………………..…………………………..…………..
……………………………………………………………………………………………………………………………………………………….
Current Record of title provided
FORM 2 Rev. 10
Updated 22/11/2019
Page 4 of 4
Designer
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Engineer
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Builder
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Gasfitter
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Drainlayer
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Plumber
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Electrician
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Other
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
The building work requires a new or altered compliance schedule - Complete Form 27 with building consent application
The building work will not affect the existing compliance schedule
There are no specified systems in the building
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Form 2: Application for project information memorandum: andor (Queenstown Lakes District Council New Zealand)

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Completed 10 November 2020

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