To | The National Commander New Zealand Fire Service C/- [name and address of Fire District Office in which building is located] |
From | Full name of building owner: *Full name of person authorised by building owner to make the application (authorised applicant): Postal address of building owner*/authorised applicant*: Telephone number of building owner*/authorised applicant*: Fax number of building owner*/authorised applicant*: Email address of building owner*/authorised applicant*: |
*Delete if inapplicable. |
[Note: The owner, in relation to a building for which a unit plan within the meaning of section 2 of the Unit Titles Act 1972 has been deposited, means the body corporate. In any other case, the owner of a building is the person, for the time being, entitled to receive the rack rent for the building, or who would be entitled to receive the rack rent if the property were let at a rack rent.] |
[Note: If the applicant is not the building owner but a person authorised by the building owner to make the application, proof of authorisation must be attached to this application.] |
[Name of building owner] seeks approval of the evacuation scheme for the building described below: |
1 | General information Name of building: Certificate of title reference and legal description of land on which building located: Street address of building: |
2 | This is an application for a new*/existing* building. |
*Delete one. |
3 | Is this an application for approval of a voluntary scheme under section 21H of the Fire Service Act 1975? Yes*/No* |
*Delete one. |
[Note: If the answer is "Yes", go to question 5.] |
4 | The building requires an evacuation scheme because the building is used for the following purposes: *the gathering together, for any purpose, of 100 or more persons: *providing employment facilities for 10 or more persons: *providing accommodation for more than 5 persons (other than in 3 or fewer household units): *storing or processing hazardous substances in quantities exceeding the minimum amounts prescribed in Schedule 2 of the Fire Safety and Evacuation of Buildings Regulations 2006: *providing early childhood facilities (other than in a household unit): *providing nursing, medical, or geriatric care (other than in a household unit): *providing specialised care for people with disabilities (other than in a household unit): *providing accommodation for persons under lawful detention (not being persons subject to home detention). |
*Delete if inapplicable. |
5 | The average number of occupants of the building is: [total number of occupants and, if building has more than one floor, the number of occupants per floor] |
[Note: Completing this paragraph is optional.] |
6 | The building has*/does not have* an automatic sprinkler system. |
*Delete one. |
[Note: If the building does not have a sprinkler system, go to question 9.] |
7 | The sprinkler system is installed*/is not installed* in accordance with one of the standards specified in regulation 16 of the Fire Safety and Evacuation of Buildings Regulations 2006. |
*Delete one. |
[Note: If the sprinkler system is not installed in accordance with a standard, go to question 9.] |
8 | The standard the sprinkler system is installed to is: |
9 | The building does*/does not* store or process 1 or more hazardous substances in an amount or amounts exceeding the minimum amounts prescribed in Schedule 2 of the Fire Safety and Evacuation of Buildings Regulations 2006. |
*Delete one. |
[Note: If the building does not store or process hazardous substances exceeding the minimum amounts, go to question 11.] |
10 | The following hazardous substances exceeding the minimum amounts are stored or processed in the building: [List the approximate aggregate quantity of hazardous substances with each relevant hazard classification against that classification.] |
11 | The building is*/is not* required to have an emergency plan under the Hazardous Substances and New Organisms Act 1996. |
*Delete one. |
[Note: Completing this paragraph is optional.] |
12 | The building is occupied— AM: PM: |
[Note: Completing this paragraph is optional.] |
[Note: If this paragraph is completed, the times listed must be the times when the building is occupied under normal circumstances (for example, normal working hours, shift hours, overtime hours, and afterhours). If different times apply on different days of the week this should be clearly stated (for example, if the building is intermittently occupied by users other than under normal circumstances (such as a school used by people in the evenings)). If any part of the building is closed or not able to be occupied at certain times, provide relevant information.] |
13 | The maximum occupancy of the building at any time is: [maximum number of occupants]. |
[Note: Completing this paragraph is optional.] |
14 | The place of safety for the building is*/places of safety for the building are*: |
*Delete one. |
[Note: If the building has an automatic sprinkler system that satisfies a standard specified in regulation 16 of the Fire Safety and Evacuation of Buildings Regulations 2006, the place or places of safety may be inside or outside the building. In every other case, the place or places of safety must be outside the building.] |
15 | Method of alerting building’s occupants to a fire emergency in the building: [Describe how notification is given (for example, an alarm sounding throughout the building is activated by the person who discovers the fire), including reference to any fixed fire detection or fire suppression systems in the building (for example, smoke detectors).] |
16 | Actions to be taken by building’s occupants: [Describe how the building occupants are informed of the measures they should take once alerted to a fire emergency, and the need, if necessary, to evacuate to the place or places of safety for the building when an alarm of fire is made. Describe in detail all the means of escape from fire for the building, including alternative routes if any primary route is unable to be used.] |
17 | The building’s occupants are informed of the place of safety and the fastest way to get to it*/places of safety and the fastest way to get to them*: [describe how occupants are informed] |
*Delete one. |
18 | Additional information in relation to evacuations to a place or places of safety inside the building: [State how the place or places of safety are safe from fire and how various fire scenarios in the building will be managed.] [State how the place or places of safety are capable of accommodating all building occupants likely to be evacuated.] [If any hazardous substances are contained or processed at the place or places of safety, state how the occupants will be protected from them.] [State how the building occupants are notified of the need, if necessary, to evacuate to another place whether inside or outside the building.] |
[Note: Complete this paragraph if the place or places of safety for the building is or are inside the building.] |
19 | The persons who will remain, in a fire emergency, with the building’s occupants at the place or places of safety inside the building are: [specify by name or position held] |
[Note: Complete this paragraph if the building has an automatic sprinkler system and the evacuation scheme is designed to enable evacuation in a fire emergency to a place or places of safety inside the building.] |
[Note: Regulation 19(2)(b) of the Fire Safety and Evacuation of Buildings Regulations 2006 requires the building’s occupants, in a fire emergency, to be evacuated from the place or places of safety inside the building to a place or places of safety outside the building if directed to do so by a member of the Fire Service or a person referred to above.] |
20 | Firefighting equipment available: [List any firefighting equipment available for use by the building’s occupants and the location of the equipment.] |
21 | Display of signs and notices: [Provide copy of signs and notices. State where in the building they are located.] |
[Note: Signs must comply with regulation 17(e) and clause 1 of Schedule 3 of the Fire Safety and Evacuation of Buildings Regulations 2006.] |
22 | Evacuation of people with disabilities: [Describe the location of the place or places in the building where, in a fire emergency, any occupants who are persons with a disability will gather if they are unable to use the building’s means of escape from fire to evacuate. Describe how the occupants are notified of this place. Describe how, in a fire emergency, attending firefighters are notified of the place or places and whether anyone is at the place or places.] [If there is specific equipment for assisting persons with a disability to evacuate, state what it is and how people are trained in its use.] |
23 | Trial evacuations/evacuation training programmes: Either *(a) trial evacuations— (i) will be conducted in the manner set out in clauses 2 to 4 of Schedule 3 of the Fire Safety and Evacuation of Buildings Regulations 2006 at the following intervals: [state frequency, which must be at intervals of not more than 6 months]; and (ii) will be managed by the following person: [describe by position not name if possible] or *(b) an evacuation training programme— (i) will be implemented in the manner set out in clauses 5 to 7 of Schedule 3 of the Fire Safety and Evacuation of Buildings Regulations 2006; and (ii) will be managed by the following person: [describe by position not name if possible]. |
*Delete one. |
[Note: There is no option in relation to a building used for the purpose of providing early childhood facilities (other than in a household unit) or as an educational institution. Trial evacuations must be held for it. See regulation 17(g) of the Fire Safety and Evacuation of Buildings Regulations 2006.] |
24 | Training of staff to manage evacuation: [Details of training undertaken by staff to manage an evacuation, and how capabilities for managing evacuation will be maintained.] |
[Note: Complete this paragraph only if question 23(a) applies.] |
25 | Special provisions or conditions: [Include any special provisions or conditions required for the proposed scheme (for example, what happens if a sprinkler or means of warning system is shut down or becomes inoperative) or whether there are any legal restrictions on the maximum number of building occupants at any particular time.] |
[Note: Completing this paragraph is optional.] |
26 | The owner of the building will notify the National Commander, in writing, if 1 or more of the following events occurs: building work is carried out on the building under section 112 or 133AT of the Building Act 2004 resulting in its means of escape from fire being significantly affected: the means of escape from fire for the building are required to be altered as a specified system under section 107 of the Building Act 2004: if the building is a building with a specified intended life within the meaning of section 7 of the Building Act 2004, its life is extended under section 116 of that Act: the occupancy of the building is changed to the extent that its means of escape from fire are no longer adequate: the building is no longer required to have an evacuation scheme (for example, the building is demolished or is no longer used for a purpose described in section 21A(1)(a) to (h) of the Act).
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