08/2078 - MCU - Detached House [As Published] · 132008.2078

INTEGRATED PLANNING ACT 1997 Part A, Version 3.1, 3 March 2008

2. _ Identify if any of the following apply to the premises by completing Tables D, E, or F. (Note: in most instances, the premises will not involve any of the
following characteristics, however some applications may involve one or more of these characteristics - complete only if applicable)

Table D Complete if the premises are adjacent to or associated with a water body, watercourse or aquifer (e.g. river. creek, lake, cana)
Name of water body, watercourse or aquifer (/f known)

 

 

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Table E Complete if the premises are on Strategic Port Land under the Transport infrastructure Act 1994
Lot on plan description for strategic port land Port authority for the lot

 

 

 

 

 

 

Table F Complete if the premises are in tidal water
Name of local government for the tidal area (/ applicable) Name of port authority for the tidal area (if applicable)

 

 

 

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3. _ Indicate the total area of the premises on which the development is proposed: (Note: The total area may inctude land both above and below water)
Total area of premises {land on which the development is proposed}

SIS ilo /\9 [ne Lo hectares (+ applicabie unit)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Existing use of the premises
4, Current use/s of the premises: (e.g. vacant land, house, townhouses, apartment building, shop, service station, school, sugar cane farming etc.)
HOUSE

5. Are there any existing easements on the premises? (eg. for vehicular access, electricity, overtand flow. water etc.)
No oO Yes - Ensure the type, location and dimensions of each easement are included in plans, submitted with the application

 

 

 

 

Proposal details
6. Brief description of the proposal: (e.g. 6 unit apartment building, 30 lot residential subdivision, a bore, aquaculture etc}

Residential Dwelling

7 ae ZF , .
7. Does the proposal include new building work or operational work (including any services) on the premises?
oO No Ye8 - Ensure the nature, location and dimensions of the proposed works are included in plans, submitted with the application

 

 

 

 

Resource entitlement (applicable) — further information is provided in the advice section at the end of the form
8. Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the application
ane State land (eased and freehold), declared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.}
No - Gow ag oO Yes - Complete Table G - provide details for each evidence fequired on a separate row, if applicable. Evidence of resource allocation or
entitlement must be submitted with the application. You do not need to answer Q9 - go to the next section.
Nature of State-owned resource
Table G [Nature of evidence required

Allocation/entitlement
reference number

 

 

 

State Goverment Date of | Date of

Name of authorising officer Position of authorising officer Department issue _| expiry

 

 

 

 

 

 

 

 

 

 

Owner's consent (applicable) - further information is provided in the advice section at the end of the form

9. Complete Table H for applications involving a material change of use; reconfiguration of a lot; work on jand below high-water mark and not
within a canal as defined under the Coasia/ Protection and Management Act 1995, or work on rail corridor land defined under the
Transport Infrastructure Act 1994 - provide details for cach owner on a separate row, of on an attachment to this form if applicable.

 

 

 

 

 

 

 

Table H Premises Owner's namels Details of the premises owned . Date consent
and postal address (street address or tot on plan description) owrers Sonate was obtained
1, [TEREmY Mary 4 Orbe ST
Te WhER GeocAbasy 20) PELEGAN GEN q{rfos
Brow Late 2 4h,

 

 

* owner's signature cannot be provided on the form if you intend to submit the application electronically. Owner's consent must be provided to the assessment manager on an
attachment containing appropriate written documentation of the ovmer's consent. If the cwner is a company, $127 of the Corporations Act 2007 (Cwealth) details how a
company may sign as owner. Templates for the provision of owner's consent ara available on the IPA website .

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