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

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Form 2: Application for project information memorandum: and/or (Gore 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
Central Otago District Council
Clutha District Council
Dunedin City Council
Gore District Council
Invercargill City Council
Mackenzie District Council
Queenstown Lakes District Council
Southland District Council
Timaru District Council
Waimate District Council
Waitaki District Council
OFFICE USE ONLY:
Consent Number:
…………………………………
PIM Number:
…………………………………
Compliance Schedule No:
………………………………….
Date received:
………………………………….
Street address 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: …………..……………
Floor area: …………………..…..… (m
2
) [Indicate area affected by the building work]
Current, lawfully established, use: ……………………………………… Year First Constructed: ………………
[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 Memorandum (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: ………………….……..…
Staged Consent – 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
This is my address for service and I acknowledge that some communications may be by email.
Please nominate if email address is not available
DESCRIPTION OF BUILDING WORK: (Provide sufficient information below to enable scope of work to be fully understood)
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
……….…………………….……………………….……………………….………..…………….…………………….……………………………………………
Current use of building: ............................................................................................................ [E.g. Home, implement shed, office]
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:
…………………………………………………………………………………..........………………………………………………………………………………
Intended life of the building if less than 50 years: ……………… [Years]
List Building Consents previously issued for this project (if any): …………………………………………………………………………………………………...……
Estimated 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]
Is prescribed energy work to be part of this Building Consent (tick if applicable) Gas Electricity
SBCG FORM 2
Version - 1 November 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: ………………………………………………………..….………
THE FOLLOWING EVIDENCE OF OWNERSHIP IS ATTACHED:
Certificate 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
Or : (If different to above details) Name :………………………………………………….. Email:…………………………………………………..
Mailing Address:……………………………………………………… Phone: …………………..……. Facsimile:……………………….
…………………………………………..…………
BILLING (PAYER) DETAILS: Owner Agent Other, (state name & mailing address) ……………………………………………………...
……………………………………………………………………………………………………
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]
………………………………………………………………………………………………………………………………………………..……….…..…
SBCG FORM 2
Version - 1 November 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
Licensing Class
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 Alternative Solution Waiver/Modification
Accessible
Design
Method
Please complete
Form SBCG 34.1
Please complete
Form SBCG 23.1
□
B1
Structure
□ B1/AS1 □ B1/AS3 □ B1/VM1 □ □
□ B1/VM4
□
B2
Durability
□ B2/AS1 □ B2/VM1 □ □
□
C1-6
Protection from fire
□ C/AS1 □ C/AS2 □ C/VM1 □ □
□ C/VM2
□
D1
Access routes
□ D1/AS1 □ □ D1/VM1 □ □
□
D2
Mechanical installation for
□ D2/AS1
□ □
D2/AS2
□ □ □
access
□ D2/AS3
□
E1
Surface water
□ E1/AS1 □ E1/VM1 □ □
□
E2
External moisture
□ E2/AS1 □ E2/AS2 □ E2/VM1 □ □
□ 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)
SBCG FORM 2
Version - 1 November 2019
Page 3 of 4
9. COMPLIANCE SCHEDULE (specified systems are defined in regulations)
The specified systems for the building are as follows:
The following specified systems are being altered, added to,
or removed in the course of the building work:
or
There are no specified systems in the building.
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 Certificate of title provided
Please provide the details required by completing either form:
• SBCG27 Compliance Schedule Specified Systems (or)
• SBCG11 Application for amendment to Compliance Schedule
SBCG FORM 2
Version - 1 November 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: ...................................................
13. Applicant / Agent’s Check
Tick if provided or note as N/A where not applicable
Landowners information
This information should match information found on
the rates assessment or Certificate of Title
Certificate of Title provided
A Certificate of Title is mandatory for ALL new buildings,
extension to buildings, building envelope change, change of use
of building and some drainage works
Owners Agent information
This is only relevant when agent is working on behalf of the owner
Building Location
This information can be found on the rates assessment, Certificate
of Title, or a Sales and Purchase Agreement
Description of Work
What is the building consent application for? Does the
description of work accurately represent the work being undertaken?
Intended Use
This is the buildings use eg. dwelling
Building Code Clauses
Method of compliance with the Building Code
Value of Work
What is the value of work that is covered by the consent application
Application Form Signed
The application cannot be accepted if not signed
Memorandum – Certificate of Design Work
Has the designer provided the Form 2A for RBW
Licensed Building Practitioners identified (Form 2A)
Yes Some known Not yet identified
Are the Designer and LBP’s specified licensed for the
RBW being undertaken
Registered Architect and CP-Engineer are deemed to
be licensed Designers
Council Use Only
Y N/A
Application Form 2 Complete
Form 2A – Certificate of Design - RBW
Site Plan
Elevations
Floor Plan (existing, proposed, new)
Truss Details
Producer Statement
Specification (job specific)
Heater Installation & Flue Details
Plumbing & Drainage Plans
2 Complete Sets of Documents (x 2)
PIM (transportable)
Certificate of Title provided
The above is satisfactory for this application to be
accepted for processing: Y N Date: ............................
First Point of Contact Consent posted to
Owner Agent Owner Agent
Consent Fees
Building Consent $ ......................................................
Accreditation Levy $ ......................................................
BRANZ Levy $ ......................................................
DBH Levy $ ......................................................
Street Asset Deposit $ ......................................................
Resource Consent $ ......................................................
Other (CS, CT etc.) $ ......................................................
Total Fee Payable $ ......................................................
Paid on application Yes To be invoiced
Receipt Number .........................................................
Cash/Chq/Eftpos/EB
Invoice to: Owner Agent Other
14. Miscellaneous
Vehicle Access
Street Crossing New Existing
Rural Access New Existing
Rapid No. Required Yes No
Street No. Required Yes No
Note: All new or altered vehicle access require approval from the Roading
Department prior to installation. Street numbers and RAPID numbers must be
issued by Council’s GIS Department – please do not allocate or assume numbers
yourself.
Utilities
New Water Connection Yes No
New Sewage Connection Yes No
New Stormwater Connection Yes No
Note: If a new water connection is required, there is a separate application form
and fee payable. Please enquire at the reception area in the Regulatory
Department.
Trade Waste
The Trade Waste Bylaw 2008 regulates the discharge of Trade
Waste to Gore District Council’s Sewerage Systems operated by or
on behalf of the Council as Wastewater Authority.
Does this consent require:
Trade Waste to be considered? Yes No
Has an application been lodged? Yes No
Approvals
Checked
Date
NA
Building
Plumbing
Drainage
Planning
Roading
Utilities
Reserves
Licensing
Parking
External Engineer
NZ Fire Service
Yes No
Compliance Schedule Required
Section 37 Notice Required
Section 72 - 75 Notice Required
Approved for Issue:
.......................................................................................................
Officers Signature Date
Form 2 – GDC Appendix
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Form 2: Application for project information memorandum: andor (Gore District Council New Zealand)

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Completed 15 November 2020

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