Ida form 122052017 · OPW17/0180

Decertment of infrastructure, Local Government and Planning

Question 10a

* The portable long service leave levy need not be paid when the application is made, but the Building and
Construction Industry (Portable Long Service Leave) Act 1997 requires the levy to be paid before a development
permit is issued.

¢ Building and construction industry notification and payment forms can be completed on the QLeave website at
www.qleave.aid.gov.au. For further information contact QLeave on 1800 803 481.

Privacy—The information collected in this form will be used by the Department of Infrastructure, Local Government
and Planning (DILGP}, assessment manager, referral agency and/or building certifier in accordance with the
processing and assessment of your application. Your personal details should not be disclosed for 2 purpose autside of
the IDAS process or the provisions abaut public access to planning and development information in the Sustainable
Planning Act 2009, except where required by legislation (including the Right fo Information Act 2009) or as required by
Parliament. This information may be stored in relevant databases. The information collected will be retained as
required by the Public Records Act 2002

OFFICE USE ONLY

 

Date received Reference numbers

 

NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER
To |. Council, | have been engaged as the private certifier for the
building work referred to in this application
{ tGainivane: (aki
Date ofengagement | Name Building

classification/s
| |

|

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

 

BSA Certification license
number

 
  

 

  

 

 

 
   

Date receipted
form sighted by
assessment
manager

Name of officer
who sighted the
form

   

Description of the work QLeave project Amount paid
($)

ruber Date paid

    
   
    

The Sustainable Planning Act 2009 is administered by the Department of Infrastructure, Local Government and
Planning. This form and all other required application materials should be sent to your assessment manager and any
referral agency.

(DAS form 1—Application details
Version 4.3—5 December 2016