Ku-ring-gai Council

818 Pacific Highway, Gordon NSW 2072

PH:
PH 02 9424 0000 FAX:
FAX 02 9424 0001
DX:
DX 8703 Gordon TTY:
TTY 02 9424 0875
E : kmc@kmc.nsw.gov.au
W: www.kmc.nsw.gov.au
ABN:
ABN 86 408 856 411

Type of Certificate

Annual/Supplementary Fire Safety

Statement
made under the Environmental Planning & Assessment Regulations 2000
Part 9 Division 5

x Annual Supplementary

PART 1 Property Details

700 Pacific Hwy
Building Address:________________________________________________________________
Address

2071
Killara
Suburb:________________________________________Postcode:___________________
Unit block of 5 apartments
Building Description:
Description _____________________________________________________________
Managing Agent/_________________________________________________________________
Agent
Exec Estates
Nina Kovach
Name:_____________________________________________________________________
1/700 Pacific Hwy Killara NSW 2071
Postal Address:__________________________________________________________________________________

Owners Details

As above
Street Address:__________________________________________________________________________________
Phone
Phone Details

Killara
2071
Suburb:________________________________________Postcode:___________________
0402 615 487
B/H:___________________________________Mobile:_____________________________

PART 2 List of Essential Fire Safety Measures

Measures
Standard of Performance
Date
________________________________________________________________________________________________
2 August 2011
Units 1 5
AS 3786
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Attach separate sheet if insufficient space

PART 3 Owner/Agent Declaration

1/700 Pacific Hwy Killara

Nina Kovach
I,____________________________________
of address,____________________________
Certify that:
(a) Each of the essential fire safety measures listed above:
Has been assessed by a properly qualified person; and
Was found, when it was assessed, to be capable of performing to at least the standard required by
the current fire safety schedule for the building for which the certificate is issued.
2 August 2011
(b) The building has been inspected on __________________
by a properly qualified person and was found,
when it was inspected, to be in a condition that did not disclose any grounds for prosecution under
Division 7 of the Environmental Planning & Assessment Regulation 2000; and
(c) The information contained in this certificate is, to the best of my knowledge and belief, true and accurate.
2 August 2011
Date:________________________
Signed:________________________________________________________
Owner/Agent (Indicate capacity in which you are signing, if not the owner)

The current fire safety schedule for the building is attached to this statement (please tick to indicate attachment)

Notes:
1) A copy of this certificate together with a copy of the current fire safety schedule must be:
- forwarded to the Council and the Commissioner of the NSW Fire Brigades (Private Locked Bag 12, Greenacre NSW 2190)
- Prominently displayed in the building
2) A person is guilty of an offence if the person makes a statement, knowing it to be false or misleading in any important respect, in or in
connection with any document lodged with Council.Environmental Planning & Assessment Regulation 2000