ANNUAL FIRE SAFETY STATEMENT Annual statement

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					                                                                          ANNUAL FIRE SAFETY STATEMENT




FORM 15A
Owner                                                  ……………………………………….

                                                       ……………………………………….

                                                       ………………………………………
Premises
                                                       …………………………………………………………….

Type of statement
                                            q Annual                           q Supplementary

                                                            *Annual statement
name owner/agent                            I _____________________________________________________________

address                                     of ___________________________________________________________

                                            certify:
                                            (a) that each essential fire safety measure specified in this statement has been assessed by a properly
                                                 qualified person and was found, when it was assessed, to be capable of performing:
                                            (i) in the case of an essential fire safety measure applicable by virtue of a fire safety schedule, to a
                                                 standard no less than that specified in the schedule, or
(*Delete if this does not apply)            (ii) in the case of an essential fire safety measure applicable otherwise than by virtue of a fire safety
                                                 schedule, to a standard no less than that to which the measure was originally designed and
                                                 implemented, and
                                            (b) that a properly qualified person (whether the person referred to in paragraph (a) or another person)
                                                 has inspected the building and has certified that, as at the date of the inspection, the condition of the
                                                 building did not disclose any grounds for a prosecution under Division 4C of Part 7B of the
                                                 Environmental Planning and Assessment Regulation 1994, and
                                            (c) the information contained in this certificate is, to the best of my knowledge and belief, true and
                                                 accurate.

*Supplementary statement

                                            I ...........................................................................................................................
                                            of .........................................................................................................................
                                            certify:
                                            (a) that each critical fire safety measure specified in this statement has been assessed by a properly
                                                   qualified person and was found, when it was assessed, to be capable of performing to a standard not
                                                   less than that required by the current fire safety schedule for the building for which the statement is
                                                   issued, and
(*Delete if this does not apply)            (b) the information contained in this certificate is, to the best of my knowledge and belief, true and
                                                   accurate.




Identification of building
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Essential Services Annual Fire Safety Statement 17/03/2003 AM 11:40
location
                                               Street
_____________________________________________________________________
                                               side of street
_______________________________________________________________
                                               nearest cross street
__________________________________________________________
                                               house/unit no. or name
_______________________________________________________


Date of assessment                             _______________________________________________________________

Owner’s details
name                                           _______________________________________________________________

address                                        _______________________________________________________________


Essential/critical fire safety measures

      measure                                                       standard of performance (e.g. relevant Australian Standard)

eg Hose reel system                                                  AS 2441-19881

     .................................................   ...................................................................................................
     .................................................   ...................................................................................................
     .................................................   ...................................................................................................
     .................................................   ...................................................................................................
     .................................................   ...................................................................................................
     .................................................   ...................................................................................................
     .................................................   ...................................................................................................

Date of Statement                              dated this                              day of                            19

Signature                                      ______________________________________________________________
                                                                       owner/agent

A copy of this certificate together with the relevant fire safety schedule must be forwarded to the
council and the Commissioner of the New South Wales Fire Brigades.

A copy of this certificate together with the relevant fire safety schedule must be prominently displayed
in the building.




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Essential Services Annual Fire Safety Statement 17/03/2003 AM 11:40
                                                                ESSENTIAL SERVICES

                                                                        FACT SHEET

•        Occupant safety may be compromised by failure to have the essential fire safety measures regularly
         inspected and certified.

•        This statement is in relation to the inspection and assessment of essential fire safety measures installed
         within the building.

•        The owner must forward a copy of the Statement to Hornsby Council together with the $100
         registration/administration fee, a copy to the Commissioner of New South Wales Fire Brigades and
         prominently display another copy in the building.

•        Failure to do so may result in penalties being imposed under the Environmental Planning and Assessment
         Act & Regulation, eg:

    1.   Owner fails to provide an annual fire safety statement                                  $ 600
    2.   Owner fails to display annual fire safety statement                                     $ 100
    3.   Owner fails to provide supplementary fire safety statement                              $ 600
    4.   Owner fails to maintain essential fire safety measures                                  $1500
    5.   Placing a thing which obstructs a path of travel to a fire exit                         $ 300
    6.   Owner fails to keep egress paths clear                                                  $ 300
    7.   Owner fails to provide unimpeded egress through exits                                   $ 300

•        One source for finding a “suitably qualified person” to carry out the inspection of essential services, is
         found under “Fire” in the Yellow Pages.

•        The person who carries out the assessment:

    1. must inspect and verify the performance of each fire safety measure being assessed, and
    2. in the case of a (supplementary or final) fire safety certificate for a new building (not an
       alteration to, or enlargement or extension of an existing building), must test the operation
       of each item of fire safety equipment installed in the building.

•        The relevant essential fire safety measures are those specified in the most recent fire safety schedule,
         attached to one of the following:

    1. development consent for a change of building use,
    2. complying development certificate for the erection of a building or a change of building use,
    3. construction certificate for proposed building work, including building work associated with a change of
       building use, or
    4. a fire safety order.

•        A Supplementary statement is when there has been an update to the essential services already on the
         register.
•        An Annual statement is when there has been no changes to the essential services on the register.




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    Essential Services Annual Fire Safety Statement 17/03/2003 AM 11:40
                                                         Essential Services Register Reference No:
                                                         Administration Fee: $100.00 (ABN 20 706 996 972)
                                                         Date Payment Received:
                                                         ..............................................................................
                                                         Receipt No.:
                                                         .................................................................................................

INVOICE                                                  Invoice for Administration Fee -
                                                         Annual/Supplementary Fire Safety Statement
The payment of an Essential Services
Administration Fee of $100.00 is required under Hornsby Shire Council’s Fees & Charges for the Financial
Year 2001/2002.

Applicant




Premises



How to pay
Please forward your payment, together with this document

Hornsby Shire Council
PO Box 37, Hornsby, NSW 1630, or via DX 9655 Hornsby
or in person at 296 Pacific Hwy, Hornsby NSW 2077

Office Use Only
ATTACH FEE CODE 394 TO THE FOLLOWING APPLICATION NO.
Essential Services Register Reference No:

Class                           Application No.                  Year                               Type                                  Total
O                                                                02                                 ES                                    $100.00
Job Property:

Is the applicant paying the fees:              o Yes              or   o No if No, please complete details below:
Name & Address of Person Paying by Cheque:




Cashier please return Office Copy of receipt only.




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Essential Services Annual Fire Safety Statement 17/03/2003 AM 11:40