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06/1354 - MCU - Dwelling House & Lot Recon [As Published] · 132006.1354
INTEGRATED PLANNING ACT 1997 Part A, Version 2.4, 29 May 2006
PLEASE NOTE: The assessment manager may refuse to accept an application that, at the time of lodgement, fails te provide all applicable Information required by Part A
and any other relevant part of Form 1.
OFFICE USE ONLY (applicable to assessment manager's)
FEE (5) DATE | RECENING OFFICER'S | REFERENCE
RECEIVED RAME/S NUMBERIS
Notification of Engagement of Private Certifier (Opsonal format)
To. Council. | have been engaged as the private cerlifier for the building work referred to in this application.
Date ofengagement / { Accreditation Number. ___ Name: Signature:
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