Form 1 and 7 · REC14/0015

completed on the QLeave website at
www.gleave.ald.gov.au. For further information contact
QLeave on 1800 803 481 or visit

www.dleave.aid.gov.

Privacy—The information collected in this form will be used by
the Department of State Development, Infrastructure and
Planning (DSDIP), 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 a purpose outside of the IDAS process or the
provisions about public access to planning and development
information in the Sustainable Planning Act 2009, except where
required by legislation (including the Right to 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 [|Reterence numbers{|

NOTIFICATION OF ENGAGEMENT OF A PRIVATE
CERTIFIER

Tol Council. | have been engaged as the private certifier for
ithe building work referred to in this application

 

Date of Name BSA Certification license {Building
lengagement number classification/s

 

 

 

 

 

 

 

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

 

Date
receipted jName of
Date form officer who
paid —_|sighted by sighted the
lassessment|form

manager

QLeave [Amount
project paid
number ($)

Description of the
lwork