OPW15/0122 Application for Vehicle Crossover

re ee re ee er ere QLEAVE LEVY NUMBER

NOTIFICATION AND PAYMENT FORM

FORM BCi 10 V7

 

E187221

This form is issued in accordance with the Building and Construction industry (Portable Long Service Leave) Act 1991 s67(1), s76(2) and s77(1).

PO Box 512 Lutwyche Qid 4030 FREECALL PH 1800 803 481
A.B.N. 89 586 619 186

PART 1 PAYER DETAILS

Te ACA

 

Wa 4
das the payer lodged a notification with QLeave previously? YIN : N : Ifyes, please insert customer number if known (Contact QLeave).
1

Ino, leave blank
ayers Legal Name BRETT LEAHY

  
  

 

ayers Trading Name SHORELINE CONSTRUCTIONS PTY LTD Contact Person (FULL NAME)
‘applicable} BRETT LEAHY
ayer ABN 75130762873 Contiict Daytime ‘Phone No.
‘epoca 0412705972

ostal Address 12 PALM AVE , COOLUM BEACH Post Code 4573

NOTE: QLeave will typically correspond with the party named as the Payer in this section, Correspondence may include: letters, invoices and refun

PART 2. BUILDING AND CONSTRUCTION DETAILS

 

 
 

Description DWELLING

ra Plan No. bocal NOOS Certifier

Site Address _5 BANKSIA AVE, , NOOSA HEADS Post Code 4567
singe you 30/03/2015 conpicton 30/09/2015

Qwner JOHN NICKEL & JOHN DUNN

  
 

?rincipal Contractor (PC) (if appointed) - Refer to Instructions for definit

1C Legal Name BRETT LEAHY
xincipal Contractor ABN 7 5 13 0 7 6 2 8

 

PC Phone No. 0412705972

 

   
      
  
   
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Customer Type: State Gov Local Gov Other
OFFICE USE ONLY yp x
(Refer to Instructions) BC Type: Other Res Commercial Civil Minesite

Ifthe work is fully covered by an QBCC, ALeave must be notified of

the work but ro payments rec in {OB PERMIT Number is provided on NUINBER tf applieabicy OB

 

Notification for Building and Construction work more than
$ 150000 $ 721,928

 

EXEMPTION CATEGORY $0
C Leviable Cost of Work (C= A- B) (Exc. of GST) $ 721,928
D Levies Payable (At time of lodgement) Refer to information on website for levy rates $ 3,429

 

 

[$902.41 [BCTF 100 | $721.93 [PLSL 250 | $1,804.66

 

      

   
    

     

a e@=aeci-ee\iage WHS 125

. Rel Jo BUT Tei eet Cenem cel Ul MER SORRELL ed
ART 4 DECLARATION ee eee correct fo the best of my knowledge and belief.

Name BRETT LEAHY Date 9/03/2015 Signature

        
 
 

 

PART 5 PAYMENT SLIP
*ayers Name BRETT LEAHY

    

E187221

hone No. 0412705972
Levies Paid $ 3,429

AILV/00047-16 Privacy Statement - QLeave is collecting the information on this form for the purposes of administering the Building and Construction Industry (Portable Long Service Leave) Act
1991, as required by that Act. QLeave may give some or all of this information to various other Government departments and agencies, as required or permitted by law.

GREEN - PAYERS | FVIFS ASSFSSMENT AND PAYMENT COPY