Form 12a - Certificate Of Compliance With Inspection Maintenance And Reporting Procedures
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1FORM 12A
CERTIFICATE OF COMPLIANCE WITH INSPECTION
MAINTENANCE AND REPORTING PROCEDURES
Section 108(3)(c), Building Act 2004
Building WOF Number: ______________________
LBP / IQP Number: _____________________________
The Building
The Owner
Street Address:
_______________________
Owners Name:
_________________________
Legal Description:
_______________________
Contact Person:
_________________________
Building Name:
_______________________
Mailing Address:
_________________________
Location of building
_______________________
Street Address:
_________________________
Within site/block:
_______________________
Registered Office:
_________________________
Level/Unit Number:
Compliance
The inspection, maintenance, and reporting procedures of the compliance schedule have been fully
complied with during the 12 months prior to the date stated below in relation to the following specified
systems:
Please tick the box next to the specified system(s) this Form 12A relates to:
□
□
SS 1
Automatic Systems for Fire Suppression
SS 10
Building Maintenance Units
□
□
SS 2
SS 11
Emergency Warning Systems
Laboratory Fume Cupboards
□
□
SS 3.1
Automatic Doors & Windows
SS 12.1
Audio Loops
□
□
SS 3.2
Access Controlled Doors
SS 12.2
FM Radio Frequency Systems
□
□
SS 3.3
Interfaced Fire / Smoke Doors / Windows
SS 13
Mechanical Smoke Control
□
□
Emergency Power Systems for SS 1 – 13
SS 4
SS 14.1
Emergency Lighting Systems
□
□
Signs for SS 1 – 13
SS 5
SS 14.2
Escape Route Pressurisation Systems
□
□
SS 6
SS 15.1
Riser Mains
Systems for Communicating Evacuation
□
□
SS 7
Auto Backflow Preventers
SS 15.2
Final Exits
□
□
SS 8.1
Passenger Carrying Lifts
SS 15.3
Fire Separations
□
□
SS 8.2
SS 15.4
Service Lifts
Signs
□
□
SS 8.3
SS 15.5
Escalators & Moving Walks
Smoke Separations
□
□
SS 9
SS 16
Mechanical Vent / Air Con Systems
Cable Cars
_______________________________________
___________________________________________
Full Name of Licensed Building Practitioner / Independent
Signature of Licensed Building Practitioner / Independent
Qualified Person
Qualified Person
___________________
Date:
FORM12A – V3 – 23/10/2014
Page 1 of 1
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