In accordance with clause 188 of the Environmental Planning and Assessment Regulation 2000 (EP&A Reg.)

 Clause 188(1)(a)	Development is an existing building subject to a development application (DA) or an application for complying development certificate (CDC) for a change in building use.
DA or CDC number	Enter number
 Clause 188(1)(b)	Development is subject of an application for a construction certificate (CC) for building works (i.e. alteration, enlargement or extension).
CC number	Enter number

Applicant

Agreement

As the applicant, I confirm the following:

I agree to pay Fire and Rescue NSW (FRNSW) the charges set out in clause 46 of the Fire Brigades Regulation 2014 (see section 12).

The development is not subject to a fire order from a consent authority.

The exemption does not conflict with any specific condition of development consent made by the consent authority (other than as applied by clause 98 or clause 136A of the EP&A Reg.).

I agree to forward with this application all relevant documentation necessary for review and assessment by FRNSW to furnish a report (see section 6).

Name of applicant	Enter name
Applicant’s phone number	Enter phone number
Applicant’s email address	Enter email address

Remittance advice information

Invoices will be issued based on the information provided below:

ASIC company name	Remitter’s ASIC registered company name
Australian business number	ABN (not ACN)	Trading name	Remitter’s general trading name
Remittance contact name	Remitter’s contact name
Remittance street address	Remitter’s street address
Remittance email address	Remitter’s email address (generic)
Remittance phone number	Remitter’s phone number	Remittance fax number	Remitter’s fax number
Purchase order ref. no.	If applicable	Project code ref. no.	If applicable

Premises

Premises name	Premises name (if applicable)
Primary street address	Primary street address
Secondary address	Secondary street address (if applicable)
Premises suburb	Premises suburb name

Consent authority

Name of consent authority	Enter name
Authority’s phone number	Enter phone number
Authority’s email address	Enter email address

Certifier

Name of certifier	Enter name
Certifier’s phone number	Enter phone number
Certifier’s email address	Enter email address

Description of building

Existing building	Select	Year constructed (approx.)	Year
Main occupancy class	Select	Other occupancy classes	Other classes
Type of construction	Select	Largest fire compartment (m2)	Area
Effective height (m)	Height	Ground floor area (m2)	Area
Rise in storeys	RIS	Total floor area (m2)	Area
Levels contained	Levels	Total volume (m3)	Volume
Is the building likely to be subject to a fire safety study?	Select
Will the development be subject to provisions of clause 144?	Select
If more than one building, provide description of buildings/site

Installed and proposed fire safety systems

Please indicate which of the following systems are currently installed in the building, and which are proposed to be installed, upgraded or an exemption is being sought for.

Fire safety system	Existing (i.e. installed)	Seeking exemption	Proposed upgrade	Proposed new install
Fire hydrant system				
Fire hose reels				
Fire sprinkler system				
Drenchers				
Smoke/heat detection system				
Smoke hazard management system				
Emergency warning and intercom system				
Building occupant warning system				

Fire hydrant system

Installation

Is a fire hydrant system required? (if no, go to section 8)	Select
Will an existing fire hydrant system be upgraded or extended?	Select
If yes, provide description of existing and proposed extension/upgrades to the hydrant system
Size of fire main of fire hydrant system	Size mm
No. internal hydrants	Number	No. external hydrants	Number
Source of water supply	Select
Provide details on water supply (e.g. capacity in litres, max. duration at full flow, alternative sources)

Note:	Please attach a current Water pressure inquiry form from the relevant water supply authority.

Fire brigade booster (for hydrant system)

Is a fire brigade booster installed on the hydrant system? (if no, go to section 7.3)	Select
Location of booster	Detail the location of the hydrant system fire brigade booster
No. booster inlets	Number	No. booster outlets	Number
Is a block plan and markings installed?	Select
Is a fire pump installed for the hydrant system? (if no, go to section 8)	Select
Pump duty (of hydrant system fire pump/s)	Number litres/min. at Number metres (head)
Drive motors fitted to hydrant system fire pump/s	Select
Is the booster connected in series or parallel with the hydrant system fire pump?	Select

Note:	FRNSW prefers the fire pump to be connected in parallel with the fire brigade booster.

Pump room (for hydrant system)

Is a pump room provided for the hydrant system fire pump? (if no, go to section 8)	Select
Is the pump room internal and fire isolated or external?	Select
If internal, does the location comply with Australian Standard AS 2419.1-2005?	Select
Detail the location of the pump room for the hydrant system

Fire sprinkler system

Installation

Is a fire sprinkler system installed? (if no, go to section 9)	Select
What standard of performance is the sprinkler system installed to?	Select
Hazard class the sprinkler system has been installed to?	Select
Specify the design capacity of the sprinkler system (i.e. max. flow demand)	Number litres/min
Is the sprinkler system staged into pressure zones as per clause 4.6 of AS 2118.1	Select
Detail the location of the sprinkler alarm valves
Are sprinkler alarm valves located as per clause 6 of Spec. E1.5 of the NCC?	Select
Grade of water supply for sprinkler system	Select
Provide details on sprinkler system water supply (e.g. number of tanks, capacity in litres, mains connection including size, pressure and flow performance)

Fire brigade booster (for sprinkler system)

Is a fire brigade booster installed on the sprinkler system? (if no, go to section 9)	Select
Location of sprinkler system booster	Detail the location of the sprinkler system fire brigade booster
No. booster inlets	Number	No. booster outlets	Number
Is a block plan and markings installed?	Select
Is a fire pump installed for the sprinkler system? (if no, go to section 9)	Select
Pump duty (of sprinkler system fire pump/s)	Number litres/min. at Number metres (head)
No. diesel pumps	Number	No. electric pumps	Number
Drive motors fitted to sprinkler system fire pump/s	Select

Pump room (for sprinkler system)

Is a pump room provided for the sprinkler system pump? (if no, go to section 9)	Select
Detail the location of the pump room for the sprinkler system

Fire control centre/room

Does the building contain a fire control centre or room? (if no, go to section 10)	Select
Is the FCC or FCR located as per clause 3 of Spec E1.8 of the NCC?	Select
Detail the location of the FCC or FCR

Details of exemption

Please provide details on the exemption/s being sought including reasons why compliance with the specified Category 3 fire safety provisions is being objected to.

No.	Relevant NCC DtS provision	Relevant Australian Standard & clause	Justification for exemption to comply provision
Enter NCC DtS	Enter AS clause	Provide brief reason for justification

Supporting documentation

Supporting documentation required by FRNSW to assess the application for exemption must be provided:

Please list then attach any documents relevant to this application

Note:	The following are examples of supporting documentation that should accompany this application:

copy of the relevant DA, CDC of CC application

copy of current and proposed fire safety schedule

plans and specifications (e.g. site plan, architectural plans, hydrant/sprinkler system schematics)

copy of current ‘Water authority pressure inquiry’ form

other relevant information that will assist FRNSW assess the exemption

Scheduled charges

FRNSW charge for the provision of services performed in connection with statutory fire safety as per the schedule of charges identified in clause 46(5) of the Fire Brigades Regulation 2014.

The charges applicable is $2,600 for each day (or part of a day) spent by the Commissioner or a fire brigade member providing advisory, assessment or consultancy services.

Note:	For a full description of the charges applicable including terms, payment options, applying for a waiver or reduction of the charges, please refer to the FRNSW website at firesafety.fire.nsw.gov.au.

Submission of this form

This completed form is to be emailed to firesafety@fire.nsw.gov.au.

All plans and specifications required by FRNSW for assessment are to be attached to the email (or sent separately if necessary due to file size). Refer to Submitting plans and specifications to FRNSW for further information.

Contact us

For further information contact the Fire Safety Branch on (02) 9742 7434 or email firesafety@fire.nsw.gov.au.