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Amended DA Form 1
DA Form 1 — Development application details Approved form (version 1.2 effective 7 February 2020) made under section 282 of the Planning Act 2016. This form must be used to make a development application involving code assessment or impact assessment, except when applying for development involving only building work. For a development application involving building work only, use DA Form 2 — Building work details. For a development application involving building work associated with any other type of assessable development (i.e. material change of use, operational work or reconfiguring a lot), use this form (DA Form 1) and parts 4 to 6 of DA Form 2 — Building work details. Unless stated otherwise, all parts of this form must be completed in full and all required supporting information must accompany the development application. One or more additional pages may be attached as a schedule to this development application if there is insufficient space on the form to include all the necessary information. This form and any other form relevant to the development application must be used to make a development application relating to strategic port land and Brisbane core port land under the Transport Infrastructure Act 1994, and airport land under the Airport Assets (Restructuring and Disposal) Act 2008. For the purpose of assessing a development application relating to strategic port land and Brisbane core port land, any reference to a planning scheme is taken to mean a land use plan for the strategic port land, Brisbane port land use plan for Brisbane core port land, or a land use plan for airport land. Note: All terms used in this form have the meaning given under the Planning Act 2016, the Planning Regulation 2017, or the Development Assessment Rules (DA Rules). PART 1 — APPLICANT DETAILS Applicant name(s) (individual or company full name) LEeGH + Wenre KERLISAN Contact name (only applicable for companies) Postal address (P.O. Box or street address) Suburb State Postcode Country Contact number Email address (non-mandatory) Mobile number (non-mandatory) Fax number (non-mandatory) Applicant's reference number(s) (if applicable) (1 Yes -- the written consent of the owner(s) is attached to this development application FX No — proceed to 3) # Queensland Government
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Page 2
PART 2 —- LOCATION DETAILS 3) Location of the premises (complete 3.1) or 3.2), and 3.3) as applicable) Note: Provide details below and attach a site plan for any or all premises part of the development application. For further information, see DA_ Forms Gu (J Street address AND lot on plan (all ots must be listed), Or ( Street address AND lot on plan for an adjoining or adjacent property of the premises (appropriate for development in water but adjoining or adjacent to land e.g. jetty, pontoon. All lots must be listed). Unit No. | Street No. | Street Name and Type Suburb ‘7 COTLAOW_ DUE TEWANTIN a) | Postcod | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s) e uses | 26 RP /B/29 B Unit No. | Street No. | Street Name and Type Suburb b) | Postcod | Lot No. Plan Type and Number (e.g. RP, SP) Local Government Area(s) 2 CJ Coordinates of premises by longitude and latitude Longitude(s) Latitude(s) Datum Local Government Area(s) (if applicable) (] wese4 C Gpag4 C1 Other: C1 Coordinates of premises by easting and northing Easting(s) Northing(s) Zone Ref. | Datum Local Government Area(s) (if applicable) (154 LL] wese4 (155 CL] GDA94 156 C1 Other: (1 Additional premises are relevant to this development application and the details of these premises have been attached in a schedule to this development application Not required CJ In or adjacent to a water body or watercourse or in or above an aquifer Name of water body, watercourse or aquifer: | (on strategic port land under the Transport Infrastructure Act 1994 Lot on plan description of strategic port land: Name of port authority for the lot: CJ Ina tidal area Name of local government for the tidal area (if applicable): Name of port authority for tidal area (if applicable): LJ On airport land under the Airport Assets (Restructuring and Disposal) Act 2008 Page 2 DA Form 1 — Development application details Version 1.2— 7 February 2020
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Name of airport: |
(1 Listed on the Environmental Management Register (EMR) under the Environmental Protection Act 1994
EMR site identification: [
(1 Listed on the Contaminated Land Register (CLR) under the Environmental Protection Act 1994
CLR site identification: |
(Yes — All easement locations, types and dimensions are included in plans submitted with this development
application
KINo
PART 3— DEVELOPMENT DETAILS
Section 1 — Aspects of development
a) What is the type of development? (tick only one box)
cihhtateriatchenge-cfuse- [[] Reconfiguring a lot JA Operational work (1 Building work
b) What is the approval type? (tick only one box)
Ml Development permit Ol Preliminary approval El Preliminary approval that includes a variation approval
c) What is the level of assessment?
Code assessment L] Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot info 3
lots):
Create a _arasysaer 4 deiwweniay .
e) Relevant plans i
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms guide:
Relevant plans.
{4 Relevant plans of the proposed development are attached to the development application
a) What is the type of development? (tick only one box)
(1 Material change of use ~—_[[] Reconfiguring a lot CD Operational work CJ Building work
b) What is the approval type? (tick only one box)
(] Development permit (] Preliminary approval (Preliminary approval that includes a variation approval
c) What is the level of assessment?
(1 Code assessment LJ Impact assessment (requires public notification)
d) Provide a brief description of the proposal (e.g. 6 unit apartment building defined as multi-unit dwelling, reconfiguration of 1 lot into 3
lots):
e) Relevant plans
Note: Relevant plans are required to be submitted for all aspects of this development application. For further information, see DA Forms Guide:
Relevant plans.
L] Relevant plans of the proposed development are attached to the development application
(Additional aspects of development are relevant to this development application and the details for these aspects
that would be required under Part 3 Section 1 of this form have been attached to this development application
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DA Form 1 — Development application details
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|___Not required
Section 2 — Further development details
Yes — complete division 1 if assessable against a local planning instrument
Reconfiguring a lot (J Yes — complete division 2
Operational work Yes — complete division 3
Building work Yes — complete DA Form 2 — Building work details
Division 1 - Material change of use
Note: This division is only required to be completed if any part of the development application involves a material change of use assessable against a
local planning instrument.
Provide a general description of the Provide the planning scheme definition | Number of dwelling | Gross floor
proposed use (include each definition in a new row) units (if applicable) area (m*)
(if applicable)
Devers eee —
(Yes
LINo
Division 2 - Reconfiguring a lot
Note: This division is only required to be completed if an
[-] Subdivision (complete 10))
L] Dividing land into parts by agreement (complete 11))
(J Boundary realignment (complete 12))
C Creating or changing an easement giving access to a lot
from a constructed road (complete 13)
Intended use of lots created Residential
Number of lots created
(1 Yes — provide additional details below
LINo
Commercial
Industrial
Other, please specify:
How many stages will the works include?
What stage(s) will this development application
apply to?
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DA Form 1 — Development application details
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Intended use of parts created Residential Commercial Industrial Other, please specify:
Number of parts created
Current lot Proposed lot
Lot on plan description Area (m?) Lot on plan description Area (m?)
Existing or Width (m) | Length (m) | Purpose of the easement? (e.g. Identify the land/lot(s)
proposed? pedestrian access) benefitted by the easement
Division 3 — Operational work
Note: This division is only required to be completed if any part of the development application involves operational work.
[1] Road work
(J Drainage work
(J Landscaping
Other — please specify:
CJ Stormwater (2 Water infrastructure
CL] Earthworks C Sewage infrastructure
LJ Signage : C1 Clearing vegetation
C1 Yes — specify number of new lots:
LINo
$
PART 4 — ASSESSMENT MANAGER DETAILS
(1 Yes — a copy of the decision notice is attached to this development application
L] The local government is taken to have agreed to the superseded planning scheme request — relevant documents
attached
[I No
PART 5 — REFERRAL DETAILS
ee ee eee
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rf No, there are no referral requirements relevant to any development aspects identified in this development application — proceed to Part 6 Matters requiring referral to the Chief Executive of the Planning Act 2016: C1 Clearing native vegetation [J Contaminated land (unexploded ordnance) (J Environmentally relevant activities (ERA) (only if the ERA has not been devolved to a local government) (1 Fisheries — aquaculture (J Fisheries — declared fish habitat area (1 Fisheries — marine plants (1 Fisheries - waterway barrier works (1 Hazardous chemical facilities (J Heritage places — Queensland heritage place (on or near a Queensland heritage place) (J Infrastructure-related referrals — designated premises (J Infrastructure-related referrals — state transport infrastructure (J Infrastructure-related referrals — State transport corridor and future State transport corridor (1 Infrastructure-related referrals — State-controlled transport tunnels and future state-controlled transport tunnels (J Infrastructure-related referrals — near a state-controlled road intersection (1 Koala habitat in SEQ region — interfering with koala habitat in koala habitat areas outside koala priority areas C1 Koala habitat in SEQ region -- key resource areas (Ports — Brisbane core port land — near a State transport corridor or future State transport corridor (1 Ports — Brisbane core port land — environmentally relevant activity (ERA) (1 Ports — Brisbane core port land — tidal works or work in a coastal management district (Ports - Brisbane core port land — hazardous chemical facility (1 Ports — Brisbane core port land — taking or interfering with water (J Ports — Brisbane core port land — referable dams (1 Ports - Brisbane core port land -- fisheries (1 Ports — Land within Port of Brisbane’s port limits (below high-water mark) (J SEQ development area (SEQ regional landscape and rural production area or SEQ rural living area — tourist activity or sport and recreation activity (1 SEQ regional landscape and rural production area or SEQ rural living area — community activity (J SEQ regional landscape and rural production area or SEQ rural living area — indoor recreation (1 SEQ regional landscape and rural production area or SEQ rural living area — urban activity (1 SEQ regional landscape and rural production area or SEQ rural living area — combined use (J Tidal works or works in a coastal management district ( Reconfiguring a lot in a coastal management district or for a canal (Erosion prone area in a coastal management district (1 Urban design C Water-related development — taking or interfering with water CO Water-related development — removing quarry material (from a watercourse or lake) (1 Water-related development — referable dams (] Water-related development —levees (category 3 levees only) CD Wetland protection area Matters requiring referral to the local government: (1 Airport land (1 Environmentally relevant activities (ERA) (only if the ERA has been devolved to local government) (] Heritage places — Local heritage places Matters requiring referral to the Chief Executive of the distribution entity or transmission entity: (J Infrastructure-related referrals — Electricity infrastructure Matters requiring referral to: Page 6 DA Form 1 — Development application details Version 1.2— 7 February 2020
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¢ The Chief Executive of the holder of the licence, if not an individual e The holder of the licence, if the holder of the licence is an individual Infrastructure-related referrals — Oil and gas infrastructure Matters requiring referral to the Brisbane City Council: (1 Ports - Brisbane core port land Matters requiring referral to the Minister responsible for administering the Transport Infrastructure Act 1994: C1 Ports — Brisbane core port land (where inconsistent with the Brisbane port LUP for transport reasons) CJ Ports - Strategic port land Matters requiring referral to the relevant port operator, if applicant is not port operator: (1 Ports - Land within Port of Brisbane’s port limits (below high-water mark) Matters requiring referral to the Chief Executive of the relevant port authority: (1 Ports — Land within limits of another port (below high-water mark) Matters requiring referral to the Gold Coast Waterways Authority: (J Tidal works or work in a coastal management district (in Gold Coast waters) Matters requiring referral to the Queensland Fire and Emergency Service: (J Tidal works or work in a coastal management district (involving a marina (more than six vessel berths)) (1 Yes — referral response(s) received and listed below are attached to this development application [No Referral requirement Referral agency Date of referral response Identify and describe any changes made to the proposed development application that was the subject of the referral response and this development application , or include details in a schedule to this development application (if applicable). PART 6 — INFORMATION REQUEST | agree to receive an information request if determined necessary for this development application (] | do not agree to accept an information request for this development application Note: By not agreeing to accept an information request I, the applicant, acknowledge: e _ that this development application will be assessed and decided based on the information provided when making this development application and the assessment manager and any referral agencies relevant to the development application are not obligated under the DA Rules to accept any additional information provided by the applicant for the development application unless agreed to by the relevant parties e — Part 3 of the DA Rules will still apply if the application is an application listed under section 11.3 of the DA Rules. Further advice about information requests is contained in the DA Forms Guide. PART 7 — FURTHER DETAILS C1 Yes — provide details below or include details in a schedule to this development application CL] No Page 7 DA Form 1 — Development application details Version 1.2— 7 February 2020
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List of approval/development Reference number Date Assessment application references manager C1 Approval (J Development application C1 Approval (1 Development application C1 Yes ~ a copy of the receipted QLeave form is attached to this development application (J No -1, the applicant will provide evidence that the portable long service leave levy has been paid before the assessment manager decides the development application. | acknowledge that the assessment manager may give a development approval only if | provide evidence that the portable long service leave levy has been paid (1 Not applicable (e.g. building and construction work is less than $150,000 excluding GST) Amount paid Date paid (dd/mm/yy) QLeave levy number (A, B or E) $ (1 Yes — show cause or enforcement notice is attached LI No (1 Yes — the required attachment (form ESR/2015/1791) for an application for an environmental authority accompanies this development application, and details are provided in the table below LI No Note: Application for an environmental authority can be found by searching “ESR/2015/1791” as a search term at www.qld.gov.au. An ERA requires an environmental authority to operate. See www.business.qid.gov.au for further information. Proposed ERA number: | Proposed ERA threshold: L Proposed ERA name: (1 Multiple ERAs are applicable to this development application and the details have been attached in a schedule to this development application. L Yes — Form 69: Notification of a facility exceeding 10% of schedule 15 threshold is attached to this development application LI No Note: See www.business.gid.gov.au for further information about hazardous chemical notifications. Page 8 DA Form 1 — Development application details Version 1.2— 7 February 2020
Page 9
(1 Yes -— this development application includes written confirmation from the chief executive of the Vegetation
Management Act 1999 (s22A determination)
LI No
Note: 1. Where a development application for operational work or material change of use requires a s22A determination and this is not included,
the development application is prohibited development.
2. See https://www.gid.gov.au/environment/land/vegetation/applying for further information on how to obtain a s22A determination.
(1 Yes —| acknowledge that an environmental offset must be provided for any prescribed activity assessed as
having a significant residual impact on a prescribed environmental matter
[INo
Note: The environmental offset section of the Queensland Government's website can be accessed at www.qld.gov.au for further information on
environmental offsets.
LJ Yes - the development application involves premises in the koala habitat area in the koala priority area
C1 Yes - the development application involves premises in the koala habitat area outside the koala priority area
[INo
Note: If a koala habitat area determination has been obtained for this premises and is current over the land, it should be provided as part of this
development application. See koala habitat area guidance materials at www.des.gld.gov.au for further information.
Water resources
23.6) Daes this development application involve taking or interfering with underground water through an
artesian or subartesian bore, taking or interfering with water in a watercourse, lake or spring, or taking
overland|flow water under the Water Act 2000?
(1 Yes — the relevant template is completed and attached to this development application and | acknowledge that a
relevant authorisation or licence under the Water Act 2000 may be required prior to commencing development
LI No
Note: Contact the Department of Natural Resources, Mines and Energy at www.dnrme.gid.gov.au for further information.
DA templates are available from https://planning.dsdmip.gld.gov.au/. If the development application involves:
¢ — Taking or interfering with underground water through an artesian or subartesian bore: complete DA Form 1 Template 1
¢ — Taking or interfering with water in a watercourse, lake or spring: complete DA Form1 Template 2
¢ Taking overland flow water: complete DA Form 1 Template 3.
Waterway barrier works
23.7) Does this application involve waterway barrier works?
(J Yes — the relevant template is completed and attached to this development application
LI No
DA templates are available from htips://planning.dsdmip.qld.gov.au/. For a development application involving waterway barrier works, complete
DA Form 1 Template 4.
(1 Yes - an associated resource allocation authority is attached to this development application, if required under
the Fisheries Act 1994
[INo
Note: See guidance materials at www.daf.qid.gov.au for further information.
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(1 Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
LINo
Note: Contact the Department of Naturai Resources, Mines and Energy at www.dnrme.gid.gov.au and www.business.qld.gov.au for further
information.
(1 Yes — | acknowledge that a quarry material allocation notice must be obtained prior to commencing development
[LI No
Note: Contact the Department of Environment and Science at www.des.gld.gov.au for further information.
(1 Yes — the ‘Notice Accepting a Failure Impact Assessment’ from the chief executive administering the Water
Supply Act is attached to this development application
[INo
Note: See guidance materials at www.dnrme.gid.gov.au for further information.
(1 Yes — the following is included with this development application:
(1) Evidence the proposal meets the code for assessable development that is prescribed tidal work (only required
if application involves prescribed tidal work)
C1 Acertificate of title
LI No
Note: See guidance materials at www.des.qld.gov.au for further information.
(1 Yes — details of the heritage place are provided in the table below
[INo
Note: See guidance materials at www.des.gid.gov.au for information requirements regarding development of Queensland heritage places.
Place ID:
Name of the heritage place:
L Yes — this development application demonstrates how the proposal meets the code for a development
application for a brothel under Schedule 3 of the Prostitution Regulation 2014
LINo
Decision under section 62 of the Transport Infrastructure Act 1994
23.15)
(Yes - this application will be taken to be an application for a decision under section 62 of the Transport
Infrastructure Act 1994 (subject to the conditions in section 75 of the Transport Infrastructure Act 1994 being
satisfied)
[LINo
PART 8 — CHECKLIST AND APPLICANT DECLARATION
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| have identified the assessment manager in question 15 and all relevant referral is requirement(s) in question 17 Yes Note: See the Planning Regulation 2017 for referral requirements If building work is associated with the proposed development, Parts 4 to 6 of DAForm2-— [Yes Building work details have been completed and attached to this development application xl Not applicable Supporting information addressing any applicable assessment benchmarks is with the % development application Note: This is a mandatory requirement and includes any relevant templates under question 23, a planning report Yes and any technical reports required by the relevant categorising instruments (e.g. local government planning schemes, State Planning Policy, State Development Assessment Provisions). For further information, see DA_ Forms Guide: Planning Report Template. Relevant plans of the development are attached to this development application x Note: Relevant plans are required to be submitted for all aspects of this development application. For further Yes information, see DA Forms Guide: Relevant plans. The portable long service leave levy for QLeave has been paid, or will be paid before a C1 Yes development permit is issued (see 21) KI Not applicable e A By making this development application, | declare that all information in this development application is true and correct Where an email address is provided in Part 1 of this form, | consent to receive future electronic communications from the assessment manager and any referral agency for the development application where written information is required or permitted pursuant to sections 11 and 12 of the Electronic Transactions Act 2001 Note: It is unlawful to intentionally provide false or misleading information. Privacy — Personal information collected in this form will be used by the assessment manager and/or chosen assessment manager, any relevant referral agency and/or building certifier (including any professional advisers which may be engaged by those entities) while processing, assessing and deciding the development application. All information relating to this development application may be available for inspection and purchase, and/or published on the assessment manager's and/or referral agency's website. Personal information will not be disclosed for a purpose unrelated to the Planning Act 2016, Planning Regulation 2017 and the DA Rules except where: ¢ such disclosure is in accordance with the provisions about public access to documents contained in the Planning Act 2016 and the Planning Regulation 2017, and the access rules made under the Planning Act 2016 and Planning Regulation 2017; or e required by other legislation (including the Right to Information Act 2009); or e otherwise required by law. This information may be stored in relevant databases. The information collected will be retained as required by the Public Records Act 2002. Page 11 DA Form 1 — Development application details Version 1.2— 7 February 2020
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PART 9 —FOR COMPLETION OF THE ASSESSMENT MANAGER — FOR OFFICE USE ONLY Date received: [ Reference number(s): [ | Prescribed assessment manager Name of chosen assessment manager Date chosen assessment manager engaged Contact number of chosen assessment manager Relevant licence number(s) of chosen assessment manager Description of the work QLeave project number Amount paid ($) | Date paid (dd/mm/yy) Date receipted form sighted by assessment manager Name of officer who sighted the form Page 12 DA Form 1 — Development application details Version 1.2— 7 February 2020