Annual Fire Safety Statement printable pdf download

ANNUAL FIRE SAFETY STATEMENT

Under Clause 175-177 of the Environmental Planning and Assessment Regulation 2000

Council Reference EFS …..……..

The General Manager

if known

Sutherland Shire Council

Office Use Only

Date Received

Type of Statement

ANNUAL

Description of the

Lot No., DP or SP

____________________________________________________________________

building or part being

certified

Unit/flat/street no. or name

_____________________________________________________________

Street name ___________________________________________ Suburb _________________________

Nearest cross street ______________________________________________________________

Owners of the building

Name/s ___________________________________

or part

Address _____________________________________________________________________________

Annual Statement

Name and address of

I, __________________________________ of _____________________________________________

owner/ managing agent/

being the owner of the building described above, or the agent of the owner, certify that:

legal representative

(a) each essential fire safety measure listed below has been assessed by a properly qualified person; and

lodging this statement

(b) each essential fire safety measure was found, when it was assessed:

where an essential fire safety measure applies because it is specified in the fire safety schedule for the

building , to be capable of performing to at least the standard set out in the schedule; or

ii) where an essential fire safety measure applies although it is not specified in a fire safety schedule for

the building, to be capable of performing to at least the standard for which the measure was originally

designed and implemented; and

(c)

a properly qualified person has inspected the building and found, when it was inspected, that no fire

safety offences under the Environmental Planning and Assessment Regulation 2000 in relation to fire

safety notices, fire exits and paths of travel to fire exits had been committed; and

(d) the information contained in this statement is true and accurate to the best of my knowledge and belief.

(e) In lodging this form, the person who makes the declaration that this is an AFSS pursuant to clause 177

(1) of the EP& A Regulations 2000 declares that they are an “authorised agent or representative” of the

Owner of the Building.

NB: The date of assessment of each fire safety measure shall not be older than 3-months prior to the date of this statement

Essential Fire Safety Measures

Standard of Performance, required by the

Date of Assessment/

Installed in the Building or Part

Fire Safety Schedule

Inspection

eg. Portable Fire Extinguisher

eg BCA E1.6 & AS2444-2001

eg 1/12/2008

The owner of the building, or managing agent/ legal representative of the building owner completing this statement must sign the statement.

Signature_________________________________________

Date of Statement _______________________________________

Name

_________________________________________

Contact Phone Number ____________________________________

The capacity in which you are signing if you are not the owner of the building ___________________________________________________

eg Strata Manager, Real Estate Agent, Legal Representative

NOTE: A copy of this Statement together with the relevant fire safety schedule must be forwarded (by the owner/agent) to the Council and also

the Commissioner of the New South Wales Fire Brigades, Fire Safety Division, Locked Bag No. 12, Greenacre 2190. A copy of this Statement,

together with the relevant fire safety schedule, must be prominently displayed (by the owner) in the building. The current fire safety schedule for

the building must be attached to this statement

Annual Fire Safety Statement

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