Development Application part 1 of 2 Application Forms OPW13/0004

      DDD
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 (includingthe 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.



OFFICE USE ONLY

 Date received                                             Reference numbers


NOTIFICATION OF ENGAGEMENT OF A PRIVATE CERTIFIER

 To
      I                                 I   Council. I have been engaged as the private certifier for the buildl ng work referred
                                            to in this application




Date of engagement        Name
                                                                                                            Building
                                                                        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-IOAS form ;1
                                                                                             Version 1.018Oecember 2009