Development Application part 1 of 2 · OPW12/0084

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        Privacy-the information collected in this form will be used by the Department of Infrastructure and Planning (DIP)in
        accordance with the processing and assessment of your application. Your personal details will not be disclosed for a purpose
        outside of the IDAS process, except where required by legislation (including the Right to Information Act 2009) or as required

        by Parliament. This information may be stored in a departmental database. The information collected will be retained as
        required by the Public Records Act 2002                                          _


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        OFFICE USE ONLY                    \ no>\:.~:\O’?\1"\ent
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         Date received       r              \                  I ReferenceleI~~mbers      I \
                                                                     PR                       \
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        NOTIFICATION OF ENGAGEMENT OF.,. PRIVATE CERTIFIER


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                                                                                                          for the b uUd;"g work referred
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        Date of engagement        Name                                       BSA Certification license number
                                                                                                                    classification!s




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

                                          QLeave Project       Amount paid                        form sighted by   Name of officer who
        Description of the work                                                   Date paid
                                          Number               ($)                                assessment        sighted the form
                                                                                                  manager




          The Sustainable PlanningAct 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.



                         7                                                                         Application details-IDAS form 1
                                                                                                     Version 1.0 18 December 2009