Development Application part 1 of 2 Application Forms MCU11/0198

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NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER


                                                    Council. I have been engaged as the private certifier for the
To:
                                                    building work referred to in this application.


Date of                                                                 BSA Certification       Building
                   Name
engagement                                                              license number          classificationls




QLEAVE NOTIFICATION AND PAYMENT (for completion by assessment manager or private certifier if applicable)


                                                                               Date receipted

              Description of the work oLeave
                                             Project    Amount                 form sighted by Name of officer who
                                                                   Date ^^
                                      Number            paid (3)               assessment        sighted the form
                                                                               manager


          1


The Sustainable Planning Act 2009 (SPA) is administered by the Department of Infrastructure and Planning. This
form and all other required application materials should be sent to your assessment manager and any referral
agencies.




                                                                                         Application Dolalls --1b-As form 1
                                                                                           Vernon 10 18 December 2009