10/0334 - Detached House [As Published] · 132010.334

 

 

 

 

 

 

 

 

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 Aight 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.

 

OFFICE USE ONLY

 

Date received

 

4 (|r

 

Reference numbers

 

 

 

¥

 

NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER

 

To

 

 

 

lof 33y
t

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

 

Date of engagement

Name

BSA Certification ticense number

Buitding
classification/s

 

 

 

 

 

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

 

Description of the work

QLeave Project
Number

Amount paid

($) Date paid

Date receipted
form sighted by {Name of officer who
assessment sighted the form

manager

 

 

 

 

 

 

 

 

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 details—IDAS form 1
Version 1.0 18 December 2009