SBCG 11 Version November 2017
Application for Amendment to Compliance Schedule
(Section 106, Building Act 2004)
Form 11
Compliance Schedule N
o
:
THE BUILDING
Street address of building:
[for structures that do not have a street address, state the nearest street intersection and the distance and direction 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]
Building name:
Location of building within site/block number:
[include nearest street access]
Level/unit number:
Current, lawfully established use:
[include number of occupants per level and per use if more than one]
THE OWNER
Name of owner:
[include preferred form of address e.g. Mr, Miss, Dr, if an individual]
Contact person:
Mailing address:
Street address/registered office:
Phone number (daytime):
Phone number (after hours):
Mobile number:
Facsimile number:
Email address:
Website address:
Evidence of ownership:
[copy of certificate of title, lease, agreement for sale and purchase, or other document showing full name of legal owners(s) of the building]
THE AGENT [only required if application is being made on behalf of the owner]
Name of agent:
Contact person:
Mailing address:
Street address/registered office:
Phone number (daytime):
Phone number (after hours):
Mobile number:
Facsimile number:
Email address:
Website address:
Relationship with Owner:
[state details of authorisation from owner to make this application on the owner’s behalf]
First point of contact for
communications with the Council:
[state full name, mailing address, phone numbers(s), facsimile numbers(s) and email address(es)]
SBCG 11 Version November 2017
APPLICATION:
I request that the compliance schedule for the above building be amended as follows:
SPECIFIED SYSTEM
AMENDMENT
REASON
SS1 Automatic Systems for Fire Suppression
SS2 Emergency Warning Systems
SS3.1 Automatic Doors
SS3.2 Access Controlled Doors
SS3.3 Interfaced Fire or Smoke Doors or Windows
SS4 Emergency Lighting Systems
SS5 Escape Route Pressurisation Systems
SS6 Riser Mains
SS7 Automatic Backflow Preventers
SS8.1 Passenger Carrying Lifts
SS8.2 Service Lifts
SS8.3 Escalators and Moving Walks
SS9 Mechanical Ventilation or Air Conditioning Systems
SS10 Building Maintenance Units
SS11 Laboratory Fume Cupboards
SS12.1 Audio Loops
SS12.2 FM Radio & Infrared Beam Transmission Systems
SS13.1 Mechanical Smoke Control
SS13.2 Natural Smoke Control
SS13.3 Smoke Curtains
SS14.1 Emergency Power Systems 1 - 13
SS14.2 Signs for Systems 1 - 13
SS15.1 Systems for Communicating Evacuation
SS15.2 Final Exits
SS15.3 Fire Separations
SS15.4 Signs for Facilitating Evacuation
SS15.5 Smoke Separations
SS16 Cable Cars
ATTACHMENTS:
Copy of existing Compliance Schedule
Completed Specified Systems Forms SS1-SS16 (one for each system being altered)
SIGNATURE [of owner/agent on behalf of, and with the authority of the owner]:
Owner or Agent
Signature:
Name of person signing:
Date: _____/_____/______
click to sign
signature
click to edit
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