NC Pre Request Response App form Signed · 131999.982963.5

 

4. Location of the premises

 

 

Unit No. Street No 10 Street Bayview Road

Suburb Noosa Heads State Qld Postcode 4567
Lot no. | aria) res rms em J

1 SP174659

 

 

 

 

 

 

 

me B Lear lame Pree

(We, the applicant, declare that the above information is correct in all respects, at the time of lodgement of this
application with Council. Should any of the details given in relation to this application be changed in the future, the
applicant shall advise Council in writing prior to any such change being implemented.

 

Signature W1 OAD F OX [Date 14.11.2018
YS

 

 

OFFICE USE ONLY
Application no. | Amount paid Date paid Receipt no. Initial Date stamp

 

 

 

 

 

 

 

Receiving Officer

 

 

 

 

Payment options

 

 

 

 

 

 

 

 

 

In person 9 Pelican Street, Tewantin: 8.30 am to 4.30 pm Monday to Friday (excludes public holidays).
By mail Cheque or money order to be made payable to Noosa Council.

O Cheque lo Money order O Mastercard O Visa

Card number Expiry date Amount $

Name on card Signature of cardholder

Phone Is a receipt required? 0 Yes ONo
tn payments made by credit card will incur a 0.50% surcharge (exempt of GST) to reflect the cost of fees charged for credit card
ransactions.

 

 

 

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