08/1193 - Operational Works - Access, Car Parking [As Published] · 142008.1193

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 nol 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 (eg. river, creek, fake, cana)
; : : ‘Name of water body, watercourse or aquifer (if known) Sot

 

 

 

 

 

 

 

1. SLA.
Table E Complete if the premises are on Strategic Port Land under the Transport infrastructure Act 1994

i ___Lot on plan description for strategic portland _ ‘Port authority for the lot
1. —_—

 

Table F Complete if the premises are in tidal water

 

Name of local government for the tidal area (if applicable) Name of port authority for the tidal area (if applicable)

 

1. ————

 

 

 

 

 

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

* FT {Ole hectares (~ apotcabie uniy

 

 

 

 

 

 

 

 

 

 

 

 

     

 

 

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

 

5. Are there any existing easements on the premises? (eg. for vehicular access, electricity, overland 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

 

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6. Brief description of the proposal: (e.g. 6 unit apartment building, 30 jot residential subdivision, a bore, aquaculture etc.)

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7. Who. proposal include new building work or operational work (including any services) on the premises?
No Oo Yes ~ Ensure the nature, location and dimensions of the proposed works are included in plans, submitted with the application

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8. Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the application
involygS State land (leased and freehold), declared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.)

No - Go to Q9 oO Yes - Complete Table G - provide details for each evidence required on @ Separete row, if applicable. Evidence of resource allocation or
entitiement must be submitted with the application. You do not need to answer Q9 - go to the next section.

 

 

 

 

  

Resource entitlement (if applicable) ~ further information is provided in the advice section al the end of the form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nature of State-owned resource : |
Table G [Nature of evidence required
Allocation/entittement ws igs wr State Goverment Date of | Date oi
reference number Name of authorising officer Position of authorising officer Department issue_| expiry
1.
_-Quuner’s consent (eppcate)- futher irmaton is provident atice sectonaineendofttefimm se TT]

9. Complete Table H for applications involving a material change of use; Teconfiguration of a lot; work on land below high-water mark and not
within a canal as defined under the Coastal Protection and Management Act 1995; or work on rail corridor land defined under the
Transport infrastructure Act 1994 - provide dotaits for each owner on a separate sow, or on an attachment fo this form if applicable.

Table H

 

Premises Owner's name/s Details of the premises owned
and postal address {street address or fot on plan description)

1 [SVE  ONGEAY aN HOLY
— SES SWisves FURS

Date consent
was oblained

SYUlOsO J 2o&

Owner's signature*

 

 

 

 

 

 

 

    

 

 

* Owners Signature cannot be provided on the form if you intend to submit the application electronically. Owner's consent must be provi j@ assessment manager on an
attachment containing appropriate written documentation of the owner's consent. If the owner is a company, $127 of the Corporations Act 2001 (Cwealth) details how a
company may sign as owner. Templates for the provision of owner's consent are available on the IPA website .

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