Note: the Agent, If Nominated, Will Be the First Point of Contact for Communications With

1

Application for Project Information Memorandum and/or Building Consent (Form 2)Section 33 or section 45, Building Act 2004 / For Official use
Project Number:
Date Received:
Items marked* are mandatory for all applications. Complete this form in BLOCK CAPITALS using BLACK orBLUEink.
1. Type of Application
I request that you issue a*:
(Tick one box only)
for the building work described in this application / Project Information Memorandum (PIM) only
Building Consent only ORAmendment to Building Consent:
Building Consent including PIM
Exemption from the need for Building Consent (e.g Marquee. Refer Schedule 1 of BA04)
2. The Building
Valuation Roll Number: / Street Address*:
Legal Description*: / Lot: / DP:
Building Name (if applicable):
Number of Levels: / Level/Unit Number: / Number of Occupants*:
Floor Area*(all floors incl.): / Existing: / m2 / Additional: / m2
Current lawfully authorised use:
(refer NZBC A1 “Classified Use) / Approx year building first constructed:
(if an addition or alteration)
3. The Owner [include preferred form of address, eg, Mr, Miss, Dr, if an individual]
Owner’s Name*: / Contact Person:
(if owner is a company)
Mailing/ / Street Address/
Billing Address*: / Registered Office:
Phone Number: / Cell Phone: / Fax:
e-mail: / website:
4. The Agent (if applicable)The Agent will be the first point of contact for communications with the Council / Building Consent Authority regarding this application / building work and will receive all correspondence including all invoices.
Agent’s Name: / Contact Person:
(if agent is a company)
Mailing/ / Street Address/
Billing Address: / Registered Office:
Telephone Number: / Cell Phone: / Fax:
e-mail: / website:
5. Fencing of Swimming Pools Act 1987
Is a Swimming Pool, or Spa Pool, on this Site or associated with this Project*?
YES / NO
6. The Project
Description of the building work*
Will the building work result in a change of use of the building? * / YES / Provide details of the new use:
(Refer NZBC A1 Classified Uses)
NO
Intended life of the building*
OR / Indefinite but not less than 50 years,
Specified as: / Years (if less than 50 years)
List building consents (BC) previously / BC Number: / Description:
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] / $
7. Restricted Building Work*
Will the building work include any restricted building work? / YES / NO
Please provide the following details of all licenced building practitioners who will be involved in carrying out or supervising the restricted building work (continue on another page is necessary). If these details are unknown at the time of the application, they must be supplied before the work begins. Include LBP number or registration number if treated as being licenced under section 291 of the Building Act 2004.
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
E Mail Address:
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
E Mail Address:
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
E Mail Address;
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
Name: / LBP Number:
Licencing Class:
Mailing Address: / Phone (day):
8. Project Information Memorandum (Applicable only if applying for a PIM or combined PIM & Building Consent)
The following matters are
involved in the project:
Subdivision
Alterations to land contours
New or altered connections to public utilities
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] (use additional sheets if required)
9. Building Consent(Not applicable if applying for Project Information Memorandum (PIM) only)
The following plans, specifications and supporting 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.]
10. Means of Compliance with the New Zealand Building Code
(Not applicable if applying for Project Information Memorandum (PIM) only)
The building work will comply with the building code as follows*(use additional sheets if required):
NZBC Clause / Means of compliance¥ / Waiver/modification required¤
Acceptable Solution
(eg. AS1, AS2 etc) / Alternative Solution
B1 (Structure) / B1
B2 (Durability) / B2
C (Protection from Fire) / C1
D1 (Access Routes) / D1
D2 (Mechanical Installations for Access) / D2
E1 (Surface Water) / E1
E2(External Moisture) / E2
E3 (Internal Moisture) / E3
F1 (Hazardous agents on site) / F1
F2 (Hazardous building materials) / F2
F3 (Hazardous substances and processes) / F3
F4 (Safety from falling) / F4
F5 (Construction and demolition hazards) / F5
F6 (Visibility in Escape Routes) / F6
F7 (Warning systems) / F7
F8 (Signs) / F8
G1 (Personal hygiene) / G1
G2 (Laundering) / G2
G3(Food prep. and prevention of contamination) / G3
G4 (Ventilation) / G4
G5 (Interior environment) / G5
G6 (Airborne and impact sound) / G6
G7 (Natural light) / G7
G8 (Artificial light) / G8
G9 (Electricity) / G9
G10 (Piped services) / G10
G11 (Gas as an energy source) / G11
G12 (Water supplies) / G12
G13 (Foul water) / G13
G14 (Industrial liquid waste) / G14
G15 (Solid waste) / G15
H1 (Energy efficiency provisions) / H1
¥ / Provide reference to the relevant compliance document(s) or detail of alternative solution in the plans and specifications.
¤ / State nature of waiver or modification of building code required.
11. Compliance Schedule (Not applicable if applying for Project Information Memorandum (PIM) only)
Are there any specified systems associated with this project? *
/ YES, the following specified systems are being altered, added to, or removed in the course of the building work: (specified systems are defined in regulations)
NO, there are no specified systems associated with this project. [Go to Section 12]
Existing / New / Modified / Removed
SS1 / Automatic systems for fire suppression (for example, sprinkler systems)
SS2 / Automatic or manual emergency warning systems for fire or other dangers (other than a warning system for fire that is entirely within a household unit & serves only that unit).
SS3/1 / Electromagnetic or automatic doors or windows (for example, ones that close on fire alarm activation)
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 for fire service use
SS7 / Automatic back-flow preventers connected to a potable water supply
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 for providing access to the exterior and interior walls of buildings
SS11 / Laboratory fume cupboards
SS12 / Audio loops or other assistive listening systems
SS13/1 / Mechanical Smoke Control
SS13/2 / Natural Smoke Control
SS13/3 / Smoke Curtains
SS14 / Emergency power systems for, or signs relating to, a system
or feature specified in any of the clauses SS1 to SS13
SS14/1 / Emergency Power Systems for a system or feature specified in any of the clauses SS1 to SS13
SS14/2 / Signs relating to Specified Systems SS1 to SS13
SS15/1 / Systems for communicating spoken information intended to facilitate evacuation
SS15/2 / Final exit (as defined by A2 of the Building Code; and
SS15/3 / Fire separations
SS15/4 / Signs for communicating information intended to facilitate evacuation
SS15/5 / Smoke separations
SS16 / Cable Cars
Purpose Group: / Fire Hazard Category: / Max Occupant Load:
12. Attachments
The following documents are attached to this application:
Plans and specifications* (refer to list at section 8)
1 copy for Residential
1 copy for Commercial / Industrial
PIM only – 1 copy only of: Site plan, floor plan and elevations / Compliance Schedule (for items identified at Section 10)
Project information memorandum / Evidence of ownership* (Certificate of Title or Sale & Purchase Agreement)
Development contribution notice / Building Consent Application Checklist*
(Form 2R for Residential or Form 2C for Commercial work)
Planning Assessment form
Memoranda (Certificate of Design Work) from licenced building practitioner who carried out or supervised the design work that is restricted building work*
Application Fee
(refer Form 2R or Form 2C) / $
13. Value of Work and Fees (GST incl) / 14. Other notes or comments which you as the applicant may wish to add
Main Buildings / $
Accessory building / $
Plumbing and Drainage / $
Total Value of Work / $
Office Use Only
PIM / $
Building Consent / $
ALPHA Processing Fee / $
BRANZ Levy / $
DBH Levy / $
Certificate of Acceptance / $
TOTAL / $
Receipt No:
Date:
15. Signature
☐I understand and accept that Council may rely on this document, for the purposes of establishing compliance with the above building consent and that the content including the signature, whether electronic or not, is truly representative and authoritative of the information contained.
Signed by*:
Full Name*:
Date*:
I am the*: / Owner / Agent on behalf of, and with the authority of, the owner.

Note: The Agent, if nominated, will be the first point of contact for communications with the Council/Building Consent Authority regarding this application / building work and will receive all correspondence including all invoices.

Commercial or Industrial PIM/Building Consent Application ChecklistForm 2(C)
(in conjunction with Form 2)
Project address: / Project Number:
Complexity:
Date Received
NB: The following is required on application in sufficient detail to show compliance with all aspects of the District Plan and the New Zealand Building Code. Please complete this checklist in FULL.
Additional information may be requested during processing of the application. / Supplied / N/A / Council
PIM
Application Form 2: Completed and signed(ensure mandatory fields are completed)
Plans and specifications: (Size A3)

• One copy of plans and specifications and 1 electronic copy of all documentation
• One copy of relevant plans and specifications for amendment
• PIM only – one copy only of: Site plan, floor plan and elevations

Application fee:

• For any type of Commercial Application in this category please refer to the Kaipara District Council’s current Fees and Chargeson its website.

Certificate of Title:

• This must be supplied with all applications without exception.

Site Plan Size A3 max, showing:

• All new and existing buildings, and swimming pools in relation to all buildings and boundaries
• Legal and notional boundaries (existing and proposed), easements, waterways, shared access ways/other areas with building setbacks dimensioned
• Any heritage buildings/trees or archaeological site information known
• Building and site areas (including floor areas (m²) for all floors)
• Vehicle access, crossing location, manoeuvre, parking area
• Any hard-standing (sealed or concrete) areas with proposed drainage
• Any significant trees on the site
• All activities on a site indicated

Outline Floor plans (for all floors)
Outline Elevations
Outline Cross Sections: (if required) to showrecession plane/daylight plane and height compliance
Hazardous Substances: storage location and capacity (i.e. LPG, diesel, heating oil etcetera)
Health Licensing: surface finishes, sinks, dishwashers, food storage
Liquor Licensing: wash basins, sinks, glass washing machine
Evacuation Scheme Assessment (required for PIM): / Building Sprinkled? / Council Use
Yes / No / Yes / No / 2x Yes = Yes
Can 100 or more people gather for different purposes or activities?
Are there facilities for more than 10 employees?
Is accommodation provided for more than 5 people?
Are hazardous substances stored?
Are early childhood facilities provided?
Is specialised care for people with disabilities provided?
Is specialised nursing, medical, or geriatric care provided?
Are people in lawful detention?
Can 100 or more people gather in a common venue?
Council Use Only - Evacuation Scheme required?

STOP HERE IF THIS IS A PIM ONLY APPLICATION

See Pages 2 and 3 for Building Consent

(in addition to the above application information)

For BCA Use only: (Please complete if PIM only, otherwise BCA staff to sign page 3)

This application is accepted / declined as all relevant information has / has notbeen supplied

Signed: ...... Name: ......

Fire Service Assessment: / Yes / No / Council Use
Is this a fit out of an existing building?
Is a change of use involved? / Minor alts?
Are alternative solutions, or any application for a modification or waiver to the Building Code for means of escape from fire and fire fighting used (Clauses C1-C6, D1, F6 or F8)
Council Use Only - Send copy to Fire Service?
Date sent: / Date received: / Charges added to BC: $
NCS updated: Y / NCS updated: Y
Building Consent (in addition to the above)
Note: A Certificate of Public use may be required if public are to have access to the building prior to the issue of the Code Compliance Certificate. / Supplied / N/A / Council
Project Information Memorandum: (if already issued) plus all attached forms
Building Code Assessment showing means of compliance, e.g. AS1, AS2, Alternative Solution
Fully Detailed Foundation Plans
Levels

• proposed and existing site levels
• existing and proposed contours
• drive gradients and pedestrian access
• floor levels and finished paving levels

Drainage Plans: full design details for both foul water and storm water to approved outfalls
Detailed Floor Plans drawn toscale, fully dimensioned and with rooms identified
Detailed Elevations including door and windows showing opening sashes
Hazardous Substances: storage location and capacity of Hazardous Substances (i.e. LPG, diesel, heating oil etc)
Cross Sections: show all relevant construction details, particularly for complex sections of the construction
Timber Treatment : the species, grading and treatment of all timber specific to the project is to be specified on the drawings, ideally on the cross section, in addition to any specification references
Insulation: R-values on drawings, method of compliance identified (Schedule/Calculation/Modelling)
Electrical Plan showing all lighting and electrical outlets including fitting types
Framing Details including floor joist layout plans if applicable
Construction Details with all materials, fixings etc noted
Weathertightness Details all relevant flashing details
Internal Waterproofing Details including all wet areas and surface finishes
Plumbing Details including layout plan / schematic of water supply including HWC location, valving and all associated systems connected to the HWC plus water supply details
Specifications information limited to and relevant to this project only
Bracing Design calculations, schedule and layout plans showing specific locations in building
Roof Truss Design including layout plan, all fixings and specific design for lintels where required
Supplied / N/A / Council
Ground Conditions report: this will be either a report to show why it is assumed that the ground is “good ground” according to the Building Code, or a specific ground assessment and foundation design by a Chartered Engineer or qualified Geotechnical Engineer
Engineers Details and Design Calculations where any specific design has been carried out (e.g. steel beams)
Access and Facilities for people with disabilities: for a new building all details of compliance are required including access to and within the building, for an existing building a report is required to determine what can be reasonably upgraded to comply
Fire Report: a fire design statement is required to show compliance with the “C” clauses of the Building Code, and the drawings must reflect the detail in the report
Compliance Schedule: fill in the last page if any of the systems are, or are to be, included or modified in the building. If any Compliance Schedule items are identified provide full details of the proposed procedures for inspections and routine maintenance and to which standard those systems will be monitored and maintained to. Provide a plan identifying the locations of all specified systems.
Approvals from Other Authorities: approvals for discharges to land, air, or water from NRC. Food and Health Approval for food or liquor outlets. MAF approval for meat works, etc.
Additional attached documents

For BCA Use Only:

This application is accepted / declinedas all relevant information has / has notbeen supplied

☐I understand and accept that Council may rely on this document, for the purposes of establishing compliance with the above building consent and that the content including the signature, whether electronic or not, is truly representative and authoritative of the information contained.

Signed: ...... Name:

Supervised (if applicable)

Signed: ...... Name:

Form 2-Application for PIM/BC

Version 2

3117.01Issued: 04 July 2014