Bordertown Request to Change Existing Approval 070616 · 132005.1292.03

4. Location of the premises
Unit No.      1               Street No        253          Street           Gympie Terrace
Suburb        Noosaville                                                     State      QLD              Postcode         4566
Lot no.                       Plan type & plan no.
Lot 1                         BUP104212




5. Concurrence Agencies
Was there one or more concurrence agencies involved in the original approval?                   No
                                                                                                Yes-provide details below
Note – Under s372 of the Sustainable Planning Act 2009 the person making the request is required to give a copy of this request to all
concurrence agencies.
Concurrence Agency                                                                             Date copy given




6. Pre-request response notice
Has a pre-request response been given by a relevant entity (e.g. a concurrence agency) for this request?
 No                                                            Yes
If yes, please attach a copy of the notice.


7. Owner’s consent
Is the owner’s consent required for this request?                     No
                                                                      Yes– complete either Table A or Table B below
Note – If more than one owner of the land all owners’ details are required


Table A – owner’s consent provided on form                               Table B – owner’s consent provided on form
                                                                                              John and Carol Pulham
Owner’s name/s                                                           Owner’s name/s

I/We, the above-mentioned owner/s of the land, consent                    The owner’s written consent is attached.
to the making of this request.

Signature/s


Date




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