Annual/Supplementary Fire Safety Statement
Environmental Planning and Assessment Regulation, 2000
The hillS Shire CounCil
3 Columbia Court, Baulkham Hills NSW 2153 PO Box 7064, Baulkham Hills BC 2153
Phone 02 9843 0555 Email [email protected] Facsimile 02 9843 0409 www.thehills.nsw.gov.au
IdENtIFICatION OF BuIldINg
OWNEr’S dEtaIlS tyPE OF StatEmENt
annual Supplementary
No. lot(s):
Section: dP/SP:
Name:
address: Of
Name of Owner/agent: I
address:
address:
Email:
Suburb: Postcode:
Suburb: Postcode:
Suburb: Postcode:
date of assessment:
Phone:
Particulars of Building: Whole of Building Part only of building (briefly describe Part)
HErEBy CErtIFy tHat:
a) each of the essential fire measures listed below have been assessed, by a person (chosen by me) who was properly qualified to do so, and was found, when it was assessed, to have been properly implemented and to be capable of performing:
i) to a standard not less than required by the most recent fire safety schedule for the building for which the certificate is issued; or ii) to a standard no less than that to which the measure was originally designed and installed.
b) by inspection, a properly qualified person has certified that the condition of the building did not disclose any grounds for prosecution under division 7 of Part 9 of the Environmental Planning and assessment regulation, 2000.
c) the information contained in this statement is, to the best of my knowledge and belief, true and accurate.
The hillS Shire CounCil
3 Columbia Court, Baulkham Hills NSW 2153 PO Box 7064, Baulkham Hills BC 2153
Phone 02 9843 0555 Email [email protected] Facsimile 02 9843 0409 www.thehills.nsw.gov.au
Annual/Supplementary Fire Safety Statement
Environmental Planning and Assessment Regulation, 2000
Essential fire or other Safety Measures minimum standard of Performance Building Code of australia reference australian Standard Number
Owner: date:
Owner’s agent (authorised in writing by the building owner to submit this certification): date:
