09/1682 - Multiple Housing Type 1 - Relative [As Published] · 132009.1682

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 not involve any of the
following characteristics, however some applications may involve one or more of these characteristics — complete only if applicable)

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~~~Table‘D~ Coiipleté if the premiges are adjacent to or associated with a water body, watercourse or aquifer (ag. river, creek, lake, cana}

 

 

 

 

 

 

 

 

; LGAs . Name of water body, watercourse or aquifer (if known)

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Stable’ Goitbiete a the premises are on Strategic Port Land under the Transport Infrastructure Act 1994

| Lot on plan description for strategic port land Port authority for the tot
DeasjofiMeby COnuIer |

Lewa———aem = Tee ~ CBiipIele if the promises 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 whith the,development is'proposed) +" «+
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SrIZIB IE Co m* [hectares (~“eppiceote nip .

‘Existing use of the premises es

 

 

 

 

 

 

 

 

 

 

 

 

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4, Current use/s of the premises: (e.g. vacant land, house, townhouses, apartment building, shop, service station, school, sygar cane farming etc.)

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HOOSE _ oo.
5. Are shere.any existing eaééménts on the premises? (as for vehicular accass, electhaty, overland flow, water et.)
4 Ne yt Yes «Ensure the type, location and dimensions of each easement aro included in plans, submitted with the application

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

EXISTING HOULE + HANDICAPPED GRANNY FLAT

7. Does the proposal include new building work or operational work (including any services) on the premises?

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Yes - Ensure the nature, focation and dimensions of the proposed works are included in plans, submitted with the application
a . eo kt to 4 an .
“Resource entitlement (if applicable) ~ further information is providédin.the afiiée section atthe end. of the-form .

8. Does the application involve taking or interfering with a State resource and therefore require a resource entitlement? (e.g. the application
. involves State land (leased and freehold), dectared Fish Habitat areas, taking quarry material, taking or interfering with water under the Water Act 2000, etc.)
No ~ Goto. Q9 oO Yes ~ Complete Table G - provide details for each evidence required on a separate row, if applicable. Evidence of resource allocation or

entitlement must be submitted with the application. You do not need to answer O9 — go to the next section.
Nature of State-owned resource

 

 

 

Table G | Nature of evidence required
Allocation/entitlement thrrieinm pf ae sei State Goverment Date of '| ‘Date of
reference number Name of authorising officer Position of authorising officer Department issue _| expiry

 

 

 

 

 

 

    

 

 

 

 

jon is prévided ii the'advite Section athe end of the‘form <<. .
9. Complete Table H for applications involving a material change of use; reconfiguration 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 details for each owner on a separate row, or on an attachment fo this form if ‘applicable.

 

 

 

 

 

 

 

 

 

 

Table H Premises Owner's name/s Details of the premises-owned - Owner's signature* Date consent
and postal address (street address or lot on plan description} ' 9 VY (>| | es obtained
. pac,
1. 49 BLANCKEN LEE ROAD .
BLACK MOUNTAIN \ )
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* Owner's signature cannot be provided on the form if you intand to submit the application electronically.

. Owner's consent must be provided to the assessment manager on an
attachment containing appropriate written documentation of the owner's consent. If the owner is @ com

pany, $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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