DA Form 5

    PART 7 – CHECKLIST AND APPLICANT DECLARATION
    13) change application checklist
    I have identified the:
•   responsible entity in 4); and
•   for a minor change, any affected entities; and                                                         Yes
•   for an ‘other’ change all relevant referral requirement(s) in 10)
    Note: See the Planning Regulation 2017 for referral requirements
    For an ‘other’ change application, the relevant sections of DA Form 1 –
                                                                                                           Yes
    Development application details have been completed and is attached to this
                                                                                                           Not applicable
    application
    For an ‘other’ change application, where building work is associated with the
                                                                                                           Yes
    change application, the relevant sections of DA Form 2 – Building work details
                                                                                                           Not applicable
    have been completed and is attached to this application
    Supporting information addressing any applicable assessment benchmarks is
    attached to this application
    Note: This includes any templates provided under 23.6 and 23.7 of DA Form 1 that are
    relevant as a result of the change application, a planning report and any technical                    Yes
    reports required by the relevant categorising instrument(s) (e.g. the local government
    planning scheme, 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                                                                                            Yes
    Note: Relevant plans are required to be submitted for all relevant aspects of this
    change application. For further information, see DA Forms Guide: Relevant plans.

    14) Applicant declaration
        By making this change application, I declare that all information in this change application is true and correct.
        Where an email address is provided in Part 1 of this form, I consent to receive future electronic communications
    from the responsible entity and any relevant affected entity or referral agency for the change 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 responsible entity and/or chosen assessment
    manager, any relevant affected entity or referral agency and/or building certifier (including any professional advisers
    which may be engaged by those entities) while processing, assessing and deciding the change application.
    All information relating to this change 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
•   required by other legislation (including the Right to Information Act 2009); or
•   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 4
                                                                                             Planning Act Form 5 - Change application form
                                                                                                             Version 1.1 — 22 JUNE 2018